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MODERN   METHODS 


-OF- 


Antiseptic  Wotind  Treatment 


COMPILED    FROM    NOTES    AND    SUGGESTIONS   FROM    THE 
FOLLOWING  EMINENT  SURGEONS: 

D.  HAYES  AGNE'W,   M.  D.,  I.L,.D., 

Pro/lessor  o/  Surgery  in  the  University  oj"  Pennsylvania^   Philadelphia,   Pa, 
A.   C.   BEKNAYS,   M.  D.,  M.  A., 

Surgeon   to  Lutheran   Hospital,   and   Consulting  Surgeo?i   to  the 
City  and  Female  Hospital,  St,   Louis,   Mo. 

S.  W.  GROSS,   M.   D.,  LL.D., 

Professor  of  the  Priticiples  of  Surgery  and  Clinical  Surgery  in  the  Jefferson  Medical 
College  o/  Philadelphia, 

HUNTER  McGUIRE,   M.  D,,  LL.D., 

Surgeon  to  St.  Lukc^s  Hospital,  Richmond,  Va. 
THOS.    G.   MORTON,   >I.   D., 

Surgeon   to  the  Pennsylvania  and  Orthopaedic   Hospitals,  Philadelphia, 

N.  SENN,   M.  D.,   Milwaukee,   Wis., 

Professor  of  Clinical  Surgery  in  the  College  of  Physicians  and  Surgeons,  Chicag(y. 

STEPHEN   SMITH,   M.   D., 

Surgeon  to  Bellevue  Hospital,  Professor  of  Clinical  Surgery  in  the   University  of  the 
City  of  New   York, 

LEWIS  A.   STIMSON,  M.  1»., 

Surgeon  to  Bellevue  Hospital,  Professor  of  Clinical  Surgery  in  the  University  of  the 
City  of  Nevtj   York. 

J.  WII-MAM  WHITE,  M,  D„ 

Surgeon  to  University,  Philadelphia,  and  Ger>na?i  Hospitals,  Philadelphia. 


Published  by  JOHNSON  &  JOHNSON,  New  York. 


MODERN  METHODS 


-OF- 


ANTISEPTIC 

WOUND   TREATMENT, 


COMPILED    FROM    NOTES    AND    SUGGESTIONS    FROM    THE 
FOLLOWING  EMINENT  SURGEONS: 

r>.   HAYES  AGXEW,   M.  D.,  TJL.H., 

Professor  of  Surgery  in  the  University  of  Pennsyliiania.,   Philadelphia^   Pa. 

A.    C.    BEKNAYS,   M.  D.,  M.  A., 

Surgeon   to   Lutheran    Hospital^   and   Consulting  Surgeon  to  the 
City   and  Female  Hospital^   St.   Louis.,   Mo. 

S.   W.   GKOSS,   M.    D.,  LL.D., 

Professor  of  the  Principles  of  Surgery  and  Clinical  Surgery  in  the  Jefferson  Medical 
College  of  Philadelphia. 

HUNTEK  McGUIRE,   M.  D.,   T.T..T)., 

Surgeon  to  Si.  Luke^s  Hospital,  Richmond,  Va, 

THOS.    G.   MORTON,   M.    D., 

Surgeon   to   the  Pejinsylvania   and  Orthopaedic  Hospitals,  Philadelphia. 

N.  SENJf,   M.  ».,   Milxvaukee,  Wis., 

Professor  of  Clinical  Surgery  in  tlie  College  of  Physicians  and  Surgeons,  Chicago. 

STEPHEN   SMITH,   M.    D., 

Surgeon  to  Bellevue  Hospital,  Professor  of  Clinical  Surgery  in  the   University  of  the 
City  of  New   York. 

LEWIS   A.    STIMSON,  M.  I>., 

Surgeon  to  Bellevue  Hospital,  Professor  of  Clinical  Surgery  in  the  University  of  the 
City  of  New   York.  » 

J.  WTLLIAM  WHITE,  M.  D., 

Surgeon  to  University,  Philadelphia,  and  German  Hospitals,  Philadelphia 


PUBLISHED    BY 

JOHNSON    &    JOH  NSON, 

NEW    YORK. 


PREFACE. 


The  collection  and  publication  of  the  matter  contained  in  these  pages 
are  due  to  suggestions  recently  made  by  an  eminent  surgeon,  to  the  follow- 
ing effect: 

1st.  That  the  aseptic  and  antiseptic  methods  in  surgery  being  of  com- 
paratively recent  origin,  most  of  the  text  books  do  not  contain  concise 
information  concerning  the  details  of  their  application. 

2d.  That  the  publication  of  such  information,  together  with  some  of 
the  special  methods  practiced  by  our  leading  surgeons,  and  the  recent 
improvements  in  the  general  method,  due  to  sanitary  science,  would 
lead  to  a  fuller  appreciation  of  the  value  of  asepsis  and  antisepsis  in  gen- 
eral practice,  and  prove  interesting  to  the  profession  at  large. 

In  consequence  of  the  above  suggestions,  a  considerable  number  of 
well-known  authorities  were  invited  to  contribute  matter  relating  to  the 
different  germicides,  dressings,  and  other  details,  with  comprehensive 
directions  for  applying  them  in  private  practice. 

From  the  material  cordially  furnished  in  response  to  the  above  invi- 
eation,  this  little  book  has  been  compiled. 

The  matter  in  general  is  such  as  has  been  sanctioned  by  the  majority 
at  contributors.  Wherever  exceptions  have  been  received  they  have 
been  noted. 

In  the  arrangement  and  revision  of  the  manuscript  much  valuable 
assistance  has  been  rendered  by  Dr.  W.  T.  Gibb,  formerly  of  the  House 
Staff  of  Bellevue  Hospital. 

JOHNSON  &  JOHNSON. 


ANTISEPTIC    PROGRESS. 


If  we  inquire  into  the  history  of  the  antiseptic  treatment  we  must 
go  back  to  the  ancient  practice  of  embalming  to  find  its  first  system- 
atic use.  We  follow  it  through  the  ages  with  note  of  the  measures  taken 
by  the  fishmonger  to  preserve  his  fish,  the  housewife  her  vegetables,  the 
sailor  his  boat.  We  read  all  along  the  portent  word — putrefaction.  The 
Roman  controlling  fermentation  in  his  wine-vats  with  pitch,  the  German 
mothers  preserving  their  dead  children  on  ice,  the  Arabian  destroying 
putrescence  with  alcohol.  These  practices  of  old  were  the  forerunners  of 
our  present. 

As  applied  to  surgery  the  antiseptic  treatment,  in  a  restricted 
sense,  has  been  attempted  for  at  least  two  centuries.  Even  the 
writings  of  surgeons  of  remote  antiquity,  such  as  Paul  d'Egeneta  in 
the  seventh  century,  and  Rogerious  and  Bruno,  of  the  thirteenth  century, 
leave  evidence  that  they  grasped  the  idea  of  the  effects  of  putre- 
faction. About  this  time  Lisfranc  discussed  the  dangers  of  treating  the 
wounded  in  tents,  owing  to  the  exposure  to  the  impurities  of  the  atmos- 
phere. In  the  sixteenth  century  Ambrose  Pare  demonstrated  that  a  gun- 
shot injury  was  "not  necessarily  a  poisonous  wound  if  protected  from 
atmospheric  influences."  In  the  seventeenth  century  Megatus  states  his 
belief  that  "the  air  contains  influences  which  cause  or  favor  putrefaction, 
and  recommends  infrequent  dressings."  In  the  eighteenth  century  we 
find  that  Belloste,  Parmanus,  Anel,  Boerhaave,  Le  Dran,  Heister  and  Bil- 
guer,  adopt  the  same  view,  and  that  they  are  more  specific  regarding 
methods  of  excluding  putrefactive  influences.  Next  followed  Abernethy, 
Come,  Demeaux  and  a  long  list  of  surgeons  who  approximated  still  nearer 
the  present  antiseptic  treatment,*  but  it  remained  for  Sir  Joseph  Lister  to 
systematize  what  had  been  done  and  to  build  up  antiseptic  sm-gery  on  a 
new  principle,  namely,  the  absolute  absence  of  putrefaction  ab  initio. 

The  problem  that  Lister  sought  to  solve  may  be  briefly  stated  as  fol- 
lows :  "  On  all  objects  in  the  external  world  septic  dust  is  present — on  the 
skin  of  the  patient,  on  the  hands  of  the  surgeon  and  his  assistants,  in 
water,  in  the  air,  etc. ;  and  when  a  wound  is  made  any  introduction  of 
this  dust  must  be  carefidly  avoided,  as  it  provokes  germination,  and  ger- 
mination means  pyaemia,  gangrene  and  septicaemia.  Some  sort  of  a 
dressing  must  be  provided  which  shall  prevent  its  passage  in  an  active 
state,  and  at  each  change  of  this  dressing  the  problem  is  the  same  as  at  the 
time  of  the  infliction  of  the  wound. "f 

*Surgeon-Major  John  Martin— Antiseptic  Surgery, 
t  Cheyne's  Manual  of  the  Antiseptic  Treatment  of  Wounds. 


This  was  Listerism.  What  matters  it  that  scientists  such  as  Pasteur, 
Tyndall  and  Koch  demonstrate  that  the  dust  is  made  up  of  living  germs, 
and  classify  the  germs  as  Bacteria,  Micrococci,  Bacilli  and  Spirillae?  Lister- 
ism has  to  do  with  the  destruction  of  the  causes  of  putrefaction  without 
inquiring  as  to  their  character. 


(i 


^'t 


\'A 


/ 


4' 


Fig.  1 — Common  forms  of  Bacteria,  from  Cheyne's  Manual. 
1. — Micrococci.    2. — Bacteria.    3.-  Bacilli.    4. — Spirillae. 


Is  the  Antiseptic  Metiiod  a  Success  ? 

It  is  scarcely  necessary  to  speak  of  the  success  of  Listerism. 
The  hospitals  of  tlie  entire  world  have  adopted  it,  and,  after  years 
of  trial,  the  outcome  is  success.  The  results  are  astonishing  1  At 
Bellevue,  where  ten  years  ago  the  rule  was  pyaamia,  septicaemia  and 
few  recoveries,  now  surgical  fever  is  rare,  pus  is  unknown  and  the 
patient  eats  and  sleeps  well  from  the  first.  The  class  of  wounds 
that  always  suppurated  never  do  so  now,  and  of  this  category  are  the  com- 
pound fractures,  amputation  wounds,  excisions  and  other  major  opera- 
tions. Dr.  Stephen  Smith  says  of  the  change  at  Bellevue  :  "  It  is  a  com- 
plete vindication  of  the  antiseptic  progress  in,  perhaps,  the  most  unfavor- 
able atmosphere  in  New  York . "  Said  Prof.  Tyndall :  "  It  is  a  matter  of 
surprise  that  the  London  hospitals  have  made  such  progress."  Queen 
Charlotte's  Lying-in-Hospital  furnishes  an  illustration.  Out  of  900  cases 
in  one  year  not  one  was  lost.  If  one  reads  the  transactions  of  the  British 
Association,  or  those  of  our  American  Association  now-a-days,  there  wUl 
be  found  in  every  year's  volume  some  reference  in  praise  of  antisepsis  in 
both  hospital  and  private  practice. 

Dresden  has  changed  the  mortality  of  18  per  cent,  to  nil.  The  record 
at  Hamburg,  Vienna,  Paris,  Berlin,  St.  Petersburg,  New  York,  Philadel- 
phia, Baltimore,  Chicago  and  other  large oities,  has  demonstrated  beyond 
question  the  value  of  antisepsis.     In  private  practice  the  record  is  the 


same  throughout  the  world.  The  surgeons  of  note  who  now  dress 
wounds  by  other  than  antiseptic  methods  are  so  very  few  as  to  be  scarcely 
worthy  of  consideration.  It  would  be  impossible  to  print  in  these  few 
pages  any  considerable  part  of  the  enormous  mass  of  statistics  that  have 
been  gathered  to  prove  the  success  of  antisepsis.  Suffice  is  it  to  say  that 
the  oldest  and  most  experienced  disciples  of  Lister  do  not  now  deem 
any  wound  too  insignificant  to  be  safe  without  tre?tment  directed  toward 
the  exclusion  of  microorganisms. 


Modifications  of  Listerism. 

Formerly  all  operations  were  done  and  dressings  applied  under  a  spray 
of  a  solution  of  carbolic  acid,  which  was  usually  made  with  a  steam  appa- 
ratus. This  part  of  the  method  has  been  almost  entirely  superseded  by 
irrigation. 

The  antiseptic  par  excellence  of  early  Listerism  was  carbolic  acid.  In 
later  years  many  agents  have  been  the  subjects  of  experiments,  the  out- 
come of  which  has  been  to  establish  bichloride  of  mercuiy  (corrosive  sub- 
limate) as  the  leading  germicide,  as  the  one  best  calculated  to  insure 
aseptic  conditions  under  a  majority  of  circumstances.  It  is  now  em- 
ployed by  Sir  Joseph  Lister  himself,  who  has  not  been  slow  to  adopt  the 
modern  improvements  of  his  method.  Carbolic  acid  is,  however,  still 
extensively  employed,  as  will  be  seen  later. 

Again,  recent  investigations  by  Koch,  Schlange  and  others  have 
proven  that  dry  antiseptic  gauze  dressings,  prepared  from  Lister's  formulae, 
are  singularly  fatdty  at  best,  and  almost  worthless  unless  used  quickly 
after  being  prepared.  Consequently  moist  dressings,  made  after  new 
formulae,  are  supplanting  them.  For  remarks  concerning  subhmate  gauze, 
by  Robert  F.  Weir,  M.  D.,  Surgeon  to  tbe  New  York  Hospital,  and  a  de- 
scription of  the  modern  method  of  preparing  gauzes,  see  page  33. 


6 
Table  Showing  the  Relative  Value  of  Various  Germicides. 

From  a  recent  clinical  lecture  delivered  by  Robert  Weir,  M.  D.,  at 
the  New  York  Hospital,  published  in  the  Philadelphia  Medical  News  Dec. 

17, 1887. 

(From  the  investigations  of  Dr.  Weeks,  of  New  York.)* 
Antiseptic.  Strength.  Duration  of  exposure  to 

destroy  vitality  of  germs. 

Corrosive  sublimate, 1  to    500  10  seconds. 

«  ■"         Ito  1000  45 

"  "         Ito  2000  1}^  minutes. 

"  "  Ito  5000  3  " 

Carbolic  acid  1  to     30  15  seconds. 

"         "  Ito     40  30-60      " 

"         "  Ito     60  4  minutes. 

Alcohol,  No  effect  on  dried  germs;    very  powerful 

when  active  in  moistened  condition. 

"  absolute  alcohol,  1-12  seconds. 

"  95perct.     "       20-30 

"  66perct      "       10-15  minutes. 

Salicyclic  acid  (makes  a  stable 

solution.)       . .   1  to  600  parts  of  water,  1  " 

Ito  1000  4-5   " 

Chlorine  water,  very  unstable,  best  when  fresh,  1)^  minutes. 

hydrogen  bromide,  "  "  "        l-l>a     " 

Boracic  acid  had  no  germicidal  action  whatever;  germs  remained  uh  iff  acted  for  W 
days. 

Iodine  to  saturation  in  water  did  not  affect  germs  after  48  hours'  expostire. 

Chloride  of  zinc,  1  to  20  in  water,  had  no  effect. 

Oil  of  turpentine,  "      "       " 

Thymol,  "      "■       " 

Eucalyptol,  "      "       " 

Ointments  of  10  per  cent,  of  iodoform  and  of  iodol  of  the  same  strength  had  no  effect 
after  36  hoiu-s'  exposure. 

Iodoform  in  power  only  retarded  development  of  germs  after  12  hours'  exposure. 

Boiling  water,  and  in  fact  heat  from  165.2  deg.  to  212  deg.  F.,  destroyed  germ  Ufe  on 
contact. 

Says  Dr.  Weir  :  "Whoever  among  you  that  has  kept  abreast  with  the 
current  literature  will  not  be  surprised  at  two  things  met  with  in  the  list. 
First,  that  the  fact  taught  us  several  years  since  by  Koch  has  been  con- 
firmed by  Dr.  Weeks,  that  oily  solutions  or  mixtures  of  the  various  anti- 
septics have  no  value  other  than  is  slowly  exerted  by  the  fatty  matters 
themselves;  and  second,  that  iodoform,  concerning  the  power  of  which 
in  germs  much  has  lately  been  written,  exerts  its  germicide  action  but 
slowly.  On  this  point  of  the  value  of  iodoform  in  controlling  inflamma- 
tion— ordinary  and  tuberculous — I  may  say  that  the  clinical  experience  of 
surgeons  is  in  favor  of  its  usefulness,  and  is  decidedly  opposed  to  the 
laboratory  deductions.  Practically,  it  is  nearly  always  used  here  in  a 
dampened  condition  in  conjunction  with  the  moist  sublimate  gauze,  and 
in  this  combination  it  is  leaned  on  heavily  as  a  supporter  of  antisepsis." 

*This  article  is  entitled  "The  Antiseptic  Value  of  the  Topical  Remedies  used  in 
Ophthalmology,  and  the  Methods  of  Sterilizing  Instruments;  Tested  Bacteriologically  "— 
and  was  read  before  the  Section  on  Ophthalmology  and  Otology  at  the  Academy  of  Medi- 
cine, October  17, 1887,  by  Dr.  John  E.  Weeks,  and  will  appear  in  full  in  the  next  number  of 
The  Archives  of  Ophthalmology. 


Articles  Used  in  Antiseptic  Surgery. 

The  Operating  Table. — The  ordinary  kitchen  table  will  generally 
answer  ;  if  not,  there  is  a  table  in  nearly  every  house  that  will.  Bricks  or 
wooden  blocks  should  be  placed  under  two  legs  of  the  table  in  order  that 
the  irrigating  liquids  may  drain  off  toward  the  pail  used  for  catching  them. 


Fig.  2. — Showing  arrangement  of  rubber  sheet  for  drainage. 
Receptacles  for  Instruments,  Dressing,  &c. — The  household  dishes  may  be 
utilized  for  this  purpose  as  follows:  Washbowl  for  rinsing  sponges  or  pre- 
paring towels ;  soup  tureen  for  rinsed  sponges ;  large  platter  for  large 
instruments ;  small  platter  for  small  instruments ;  small  bowl  for  artery 
forceps  ;  saucers  for  needles,  ligatures^  sutures  and  drainage  tubes. 

Tfie  Irrigator. — Use  a  fountain  syringe  of  about  four 
quarts'  capacity,  with  a  nozzle  that  will  throw  a  strong 
single  stream.  In  cases  of  emergency  an  ii-rigator  may  be 
improvised,  by  knocking  the  bottom  out  of  a  bottle  and  per- 
forating the  cork  for  the  passage  of  a  tube. 

Rubber  tubes  for  bottle  and  syphon  irrigators  are  fiunished  by 
Johnson  &  Johnson,  N.  Y. 

The  Rubber  Sheet. — A  piece  of  rubber  cloth,  six    feet 
lif/  long  by  three  feet  wide,  is  required  to  drain  off  the  irrigat- 

ing fluids  into  the  catchpail. 

Bichloride  Solutions. — ComiKessed  tablets  of  corrosive 
sublimate  and  tartaric  acid  or  ammonium  chloride  are  most 
convenient  for  preparing  bichloride  solutions.  These  tablets 
are  prepared  so  as  to  make,  when  dissolved  in  a  pint  of 
water,  a  solution  of  1-1000.  Where  the  tablets  are  not 
used,  the  solution  should  be  made  as  follows  : 

Bichloride  of  mercury, gr.  7.50 

Kg-3.-Thiersch's  Tartaric  acid, gr.  37.50 

champagne  bot-             ^                    •            i  i      •  i  «  pa 

tie  irngator.  Or  ammonium  chloride, gr.    7.50 

which,  added  to  a  pint  of  water,  makes  a  solution  of  1-1000.  Tartaric  acid, 
or  ammonium  chloride,  is  used  to  prevent  the  precipitation  of  calomel 
and  the  formation  of  albuminate  of  mercury  when  the  fluid  comes  in  con- 
tact with  the  living  tissues. 

Dr.   Bernays  suggests  corrosive  sub. ,   gr.  7.  ;    citric  acid,  gr.  3.48  ; 
which  makes  a  solution  of  1-1000  in  one  pint  of  water. 


Dr.  N.  Senn  prefers  tablets  made  of  corrosive  sublimate  and  chloride 
of  sodium,  each  15  grains,  stained  with  analine  blue. 

Bichloride  solutions  should  never  be  made  in  a  metallic  receptacle,  as 
a  precipitate  is  immediately  thrown  down. 

Carbolic  Solutions. — Liquefied  carbolic  acid  in  a  small  bottle  is  the  most 
convenient  form  for  use.  One  ounce  in  thirty  ounces  of  water  makes  a 
1-30  solution. 

Absorbent  Cotton. — Select  cotton  that  is  prepared  in  even  layers  and 
which  has  been  sterilized  by  being  subjected  to  the  proper  degree  of  heat. 
Absorbent  cotton  is  a  very  important  factor  in  the  successful  application 
of  the  antiseptic  method.  Not  only  is  it  invaluable  as  an  absorbent  of  the 
discharges  from  the  wound,  but,  according  to  Professors  Koch,  Tyndall 
and  others,  cotton  fibre  forms  the  best  possible  obstniction  to  the  entrance 
of  germs,  after  its  natural  oil  has  been  extracted  and  it  has  been  sterilized 
by  being  subjected  to  the  proper  degree  of  heat. 

Moist  Antiseptic  Gauzes. — Bichloride,  iodoform  and  carbolated.  For  re- 
marks of  the  authorities  on  the  defects  and  unreliability  of  dry  gauzes, 
and  methods  of  preparing  moist  gauzes,  see  page  33. 

Combined  Dressing  (sheets  of  absorbent  cotton  between  layers  of  anti- 
septic gauze)  has  lately  come  into  extensive  use  at  Bellevue  Hospital  as  a 
substitute  for  cotton  and  gauze,  used  separately.  It  is  ^rifrT^uT  ^t■:'"'T'^ 
prepared  as  bandages  in  various  widths,  and  is  cut  by     I    \  •'     1 ' 

the  nurses  in  the  shape  of  a  Maltese  Cross,  as  shown  in     j  f 

fig.  4.    These  crosses  are  made  in  sizes  varying  from  3     |  \\ 

to  18  inches  square.  The  larger  ones  constitute  a  conven-  I  /'  \  1= 
lent  dressing  for  stumps  after  amputation,  and  the     pf  ^^ 

smaller  ones  for  dressing  wounds  of  the  fingers,  toes,  etc.  "Fig  4 

Lint  is  used  antiseptically  for  a  variety  of  purposes,  but  chiefly  in  the 
hospitals  as  a  dressing  for  burns,  in  connection  with  antiseptic  ointments. 

Iodoform. — A  small  bottle  of  iodoform  and  an  iodoform  sprinkler  are 
required.  A  small  glass  salt-sifter,  or  pepper  box,  such  as  may  be  obtained 
at  any  house-furnishing  store,  will  answer  for  a  sprinkler.  Select  one 
with  the  smallest  holes  through  the  top.  Remove  the  top  and  keep  the 
bottle  corked  when  not  in  use.  The  hard  rubber  iodoform  sprinkler, 
though  more  expensive,  is  preferable  on  account  of  its  convenience. 

Subiodide  of  bismuth  is  quite  extensively  employed  as  a  substitute  for  iodoform.  Its 
antiseptic  value  being  considered  about  equal  to  the  latter.  The  principal  advantage 
claimed  for  it  is  that  it  is  inodorous.    Its  cost  is,  however,  double  that  of  iodoform. 

Prof.  A.  C.  Bernays,  of  St.  Louis,  does  not  use  iodoform  in  any  case. 

For  remarks  of  Dr.  Robert  F.  Weir,  relating  to  the  value  of  iodoform,  see  page  6. 

Iodoform  Collodion. — A  10  per  cent,  iodoform  collodion  will  be  found  an 
excellent  protective  in  small  wounds,  as  those  of  the  face,  and  in  wounds 
upon  which  it  is  difficiilt  to  retain  the  ordinary  dressings,  as  after  excision 
of  a  portion  of  the  scrotum. — Prof.  S.  W.  Gross. 


Sutures. — Sutures  are  made  of  silk,  catgut,  silkworm  gut  and  silver, 
the  last  being  employed  only  in  exceptional  instances.  The  material 
which  we  furnish  for  silk  sutures  are  "  Chinese  twist"  and  braided  silk. 
Before  being  used  they  should  be  boiled  for  half  an  hour,  and  then  be 
immersed  in  the  1-1000  corrosive  solution.  Silkworm  gut  is  sometimes 
employed ;  it  is  strong,  smooth  and  of  small  diameter,  but  possesses  no 
advantages  over  silk.  If  catgut  be  used,  it  should  be  chromicized  by 
JViacewen's  process,  which  renders  it  durable  for  seven  days  and  upwards. 
This  form  of  suture  should  be  used  in  connection  with  iodoform  collodion. 

Ligatures. — For  the  purpose  of  tying  blood  vessels  the  only  materials 
recommended  at  the  present  day  are  silk  and  catgut.  The  former  is  pre- 
pared in  the  same  manner  as  the  silk  suture.  Unless  catgut  be  prepared 
with  great  care,  minute  precautions  being  taken  to  render  it  aseptic,  it 
will  defeat  the  object  of  antiseptic  operations. 

We  fumish.  catgut  in  three  sizes— 1,  8  and  3 — No.  1  being  the  smallest  and  No.  3  the 
largest.  Smaller  sizes  cannot  be  relied  upon  on  account  of  their  brittleness.  In  their 
preparation  we  foUow  the  process  of  Prof.  S.  W.  Gross,  who  informs  us  that  they  are  per- 
fectly reliable,  both  antiseptically  and  mechanically. — J.  &  J. 

"  The  commercial  catgut  is  immersed  for  half  an  hour  in  a  1  per  cent,  alcoholic  solution 
of  corrosive  sublimate,  to  which  has  been  added  5  per  cent,  of  tartaric  acid.  It  is  then 
transferred  to,  and  kept  permanently  in,  oU  of  juniper  berries,  in  which  it  must  remain  1 1 
least  ten  days  before  being  used.  Previous  to  an  operation  the  gut  is  wiped  with  a  towel 
which  has  been  wnmg  out  of  a  1-1000  watery  corrosive  solution,  when  it  is  placed  in  a  simi- 
lar solution,  to  which  has  been  added  20  per  cent,  of  alcohol.  The  alcohol  prevents  the 
material  from  swelling  and  untwisting.  Made  in  this  way,  catgut  is  thoroughly  aseptic, 
strong  and  pUable." — Prof.  S.  W.  Gross. 

"  I  would  prefer  catgut,  made  by  immersing  the  commercial  catgut  for  ten  days  in  oil 
of  juniper,  washing  it  with  sulphuric  ether  and  keeping  it  in  a  solution  of  alcohol  and  cor- 
rosive subUmate,  1-1000. "—N  Senn,  M.  D. 

Sponges. — Selected  reef  sponges  are  generally  used  in  hospitals,  but 
they  are  quite  expensive,  and  need  considerable  preparation  to  make  them 
fit  for  use,  as  they  are  filled  with  sand,  which  must  be  washed  out.  The 
Linton  antiseptic  sponges,  prepared  from  absorbent  cotton  and  wood 
fibre,  enclosed  in  fine  antiseptic  gauze,  so  as  to  give  a  soft  and  yielding 
mass,  are  preferred  by  many  physicians  in  private  practice,  as  they  are 
very  convenient  and  cheap  enough  to  be  thrown  away  after  once  using. 

Kummel's  plan  of  washing  reef  sponges  in  green  soft  soap  and  water,  then  placing 
them  in  carbolic  solution  1-30,  or  bichloride  solution  1-1000,  is  a  good  one."— Hunter  Mc- 
GuiRE,  M.  D.,  Richmond,  Va. 

Artificial  aseptic  sponges  may  be  used  for  plugging  cavities.— A.  C.  Beenats,  M.  D. 

Gutta  Percha  Tissue — Is  used  to  prevent  the  dressings  on  small  wounds 
from  drying  too  quickly,  which  allows  the  adhering  of  cutaneous  margins 
before  the  discharge  of  serum  from  the  deeper  tissues  has  ceased.  It  is 
also  used  in  connection  with  the  rubber  sheet  to  drain  off  the  irrigating 
fluid. 

Linton  Moist  Dressing  Paper. — A  preparation  of  strong  parchment  paper 
made  impervious  to  water  and  air,  flexible  and  antiseptic,  is  used  by  many 


10 

physicians  as  a  substitute  for  gutta  percha  tissue  and  oil  silk,  as  it  is  much 
cheaper. 

"  I  endorse  this,  and  would  prefer  this  article  to  anything  else."— A.  C.  Bernats,  M.  D. 

Drainage  Tubes — Are  used  to  allow  the  escape  of  blood,  pus  and  serum, 
from  wounds  and  abscesses.  They  are  made  of  decalcified  bone,  rubber 
or  glass. 

The  bone  tubes  are  said  to  be  completely  absorbed  in  the  wound  in 
about  ten  days,  which  allows  the  wound  to  heal  without  removing  the 
dressing. 

The  experience  of  the  majority  of  surgeons  is,  however,  against  bone 
drainage  tubes.     The  glass  and  rubber  tubes  are  the  best. 

Rubber  tubes  should  be  made  of  natural,  not  vulcanized,  rubber. 

Catgut  drains  are  used  for  small  wounds,  and  are  made  by  bunching 
strands  of  catgut  together. 

"  I  use  glass  drainage  tubes  in  exceptional  cases,  to  the  exclusion  of  tubes  made  of 
other  materials .  They  are  easily  sterilized  by  boUing,  and  should  be  kept  in  a  1-1000  bi- 
chloride solution."— Prof.  S.  W.  Gross. 

Esmarch's  Bandage. — An  elastic  rubber  bandage,  usually  2)^  inches 
wide  and  5  yards  long.  It  is  used  for  the  stoppage  of  hemorrhage  and  the 
depletion  of  a  part  of  blood.  In  amputations  it  is  wound  spirally  about 
the  limb,  beginning  at  the  distal  extremity,  each  turn  overlapping  the 
preceding  turn  by  one  half  an  inch. 

Other  Necessary  Requisites — Are  :  a  narrow,  sharp  razor,  for  shaving 
off  the  hairs  around  a  wound  ;  a  nail  brush,  cake  of  soap,  assorted  gauze 
bandages,  towels,  binder  and  safety  pins. 

Potash  soap  should  be  used  exclusively,  as  it  penetrates  the  epidermis  more  deeply 
than  ordinary  soap  and  is  thus  better  adapted  for  securing  an  aseptic  condition  of  the  sMn.— 
Prof.  N.  Senn,  Milwaukee,  Wis. 

The  green  potash  soap  is  by  far  the  best;  but  as  it  possesses  powerful  caustic  proper- 
ties, only  one  part  to  750  of  water,  a  proportion  which  arrests  the  growth  of  the  bacUli  of 
anthrax  should  be  employed.— Prof.  S.  "W.  Gross. 


Important  General  Directions  and  Precautions. 

Before  beginning  an  operation  see  that  all  things  required  are  ready. 

The  operator  and  assistants  should  weara  clean  white  coat  or  apron. 

A  small  table  should  be  placed  near  the  operating  table,  and  covered 
with  towels  wrung  out  in  a  1-2000  bichloride  or  1-30  carbolic  solution. 

On  this  should  be  placed  the  dishes  for  holding  the  instruments, 
needles,  &c.,  and  these  should  then  be  filled  with  a  1-30  carbolic  solution, 
into  which  the  instruments,  needles  and  sutures  should  be  placed  at  least 
half  an  hour  before  being  used. 

Two  or  three  gallons  of  bichloride  solution  will  generally  be  required. 

Instruments  are  not  placed  in  the  bichloride  solution,  as  it  dulls  them- 

Dressings  should  be  prepared  on  towels  wrung  out  in  1-2000  bichlor 
ide  solution,  and  then  rolled  up  in  the  towels  until  used. 


11 

Clean  towels,  wrung  out  in  the  above-mentioned  solution,  are  placed 
around  everything  near  a  wound,  so  that  the  instruments,  hands,  sutures, 
sponges,  &c.,  may  not  come  in  contact  with  anything  that  has  not  been 
rendered  aseptic. 

Hang  tlie  irrigator  high  enough  above  the  operating  table  to  make  it 
convenient  for  use,  and  fill  with  the  solution  you  are  going  to  use. 

"  Tlie  water  should  be  hot.  I  attach  great  importance  to  hot  solutions  applied  to  ex- 
posed surfaces,  and  should  insist  upon  the  hot  throughout." — Stephen  Smith,  M.  D.,  N.  Y. 

The  skin  about  a  wound  should  be  invariably  shaved,  whether  it  be 
coarse  and  hairy  or  delicate. 

The  part  which  has  been  shaved  should  then  be  scrubbed  with  a  stiff 
brush  and  soap-suds,  and  the  soap-suds  washed  away  with  hot  water,  and 
afterwards  with  a  1-1000  bichloride  solution. 

Instruments  should,  whenever  practicable,  be  made  entirely  of  steel  and 
be  scrubbed  and  subsequently  boiled  for  twenty  minutes  before  being  im- 
mersed in  the  carbolic  solution. 

The  hands  of  both  the  operator  and  his  assistants  should  be  thoroughly 
washed  and  scrubbed  in  a  1-1000  bichloride  solution  before  the  operation 
begins,  and  rewashed  when  any  unprepared  object  is  touched,  accident- 
ally or  otherwise,  during  an  operation. 

Professor  Bemays  lays  particular  stress  upon  the  necessity  for  cleansing  the  hands, 
especially  the  nails,  in  a  painstaking  manner;  1st,  with  a  brush  and  soap  and  water,  then 
with  antiseptic  solution.  Says  Dr.  N.  Senn  :  "Pure  spirits  of  turpentine  should  housed 
upon  the  hands  in  all  important  operations  upon  joints  or  where  a  serous  cavity  is  to  be 
opened." 

Sponges,  dressings,  instruments,  etc.,  should  be  handled  with  great 
care  both  by  the  surgeon  and  his  assistants. 

Disinfected  safety-pins  are  used  to  prevent  drainage  tubes  from 
disappearing  beneath  the  skin. 

After  inserting  a  tube,  the  part  projecting  above  the  skin  should  be 
cut  off,  and  the  safety-pin  passed  through  the  end  at  the  surface. 

Care  should  be  taken  to  bring  the  parts  into  accurate  apposition  ;  also 
to  avoid  tension,  especially  of  the  edges  of  the  wound  of  damaged  or  un- 
healthy tissues. 

While  the  wound  is  open  it  should  be  kept  wet  with  the  irrigator 
controlled  by  an  assistant. 

A  dressing  should  not  be  changed  because  serum  has  oozed  through  it. 
Place  dry  carbolized  or  other  dry  antiseptic  absorbent  cotton  over  the 
moist  places  and  allow  it  to  dry. 

Dressings,  in  some  cases,  are  not  interfered  with  until  the  wound  heals. 
They  are,  however,  changed  before  the  wound  heals  in  the  following 
cases :  1st,  to  remove  drainage  tubes  ;  2d,  when  high  temperatures 
show  that  some  antiseptic  rule  has  been  violated  ;  3d,  when  plastic  opera- 
tions are  done  ;  4th,  when  secondary  hemorrhage  occurs,  or  when  the 
patient  suffers  severe  pain. 


12 

A  temperature  of  101  deg.  F.  will  frequently  follow  an  operation  and 
remain  for  a  few  hours.  Hence  it  is  not  advisable  to  change  a  dressing 
unless  this  temperature  is  shown  36  hours  after  an  operation.  If  then 
m.3.rked  inflammation  about  the  wound  exists,  the  antiseptic  dressing 
must  be  changed  daily,  or  even  oftener.  The  main  point  to  be  observed 
in  renewing  dressings  is,  give  the  patient  absolute  rest  as  far  as  possible, 
not  changing  oftener  than  required. 

"When  a  rubber  or  glass  drain  tube  is  used,  it  should  be  gotten  out  in 
one  or  two  days,  and  the  wound  redressed. 

When  dressings  are  changed  the  second  dressing  should  be  applied 
with  the  same  care  as  the  first,  following  the  same  general  rules. 

The  patient's  general  health  should  be  attended  to.  A  supply  of  good 
food  and  fresh  air  should  be  given,  in  this  way  promoting  the  resisting 
and  healing  power  of  the  tissues. 

Iodoform  is  used  to  dust  about  the  mouths  of  drainage  tubes  and  over 
the  surfaces  of  wounds  that  are  to  remain  open  ;  also  along  the  line  of 
sutures.  It  is  not  dangerous  unless  too  much  is  used.  In  open  wounds 
enough  should  be  used  to  barely  cover  the  surface,  and  no  more. 

It  should  be  used  very  cautiously  on  the  young  and  on  granulating  surfaces.  Instead 
of  dusting  iodoform  in  a  wound  it  is  better  to  spray  the  surface  with  an  ethereal  solution 
of  iodoform. — Lewis  A.  Stimson,  M.  D.,  N.  Y. 

If  a  sponge  or  a  dressing  fall  to  the  floor  it  should  not  be  used.  If  an 
instrument  should  come  in  contact  with  any  unprepared  surface,  it  should 
be  again  scrubbed  and  go  back  into  the  carbolic  acid  solution. 

Bichloride  Poisoning. — One  observer  says  paradoxically  :  "  Corrosive 
sublimate  is  not  dangerous,  if  you  know  that  it  is  dangerous."  Like 
other  toxic  agents,  both  bichloride  and  carbolic  acid  must  be  used  with 
care.  With  regard  to  the  proper  strength  of  bichloride  solution  for  irri- 
gation, the  opinions  of  the  authorities  differ.  At  Bellevue  Hospital  a 
solution  of  1-2000  is  generally  used,  while  according  to  Dr.  Robert  F. 
Weir  ' '  a  solution  stronger  than  1-5000  is  not  deemed  safe  at  all  times  "  at 
the  Nevsr  york  Hospital.  Other  eminent  surgeons  first  wash  out  ordinary 
wounds  with  a  1-1000,  and  afterwards  with  a  1-5000  solution.  In  irrigat- 
ing the  peritoneal  cavity,  or  large  synovial  cavities,  or  the  interior  of 
the  uterus,  a  solution  stronger  than  1-5000  should  never  be  used. 

The  success  of  the  treatment  depends  upon  the  care  used  in  keeping 
the  wound  absolutely  free  from  septic  material. 

Recognition  of  these  principles,  their  study  and  adoption,  are  of  as  much  importance 
to  a  surgeon  as  a  knowledge  of  anatomy  or  manual  dexterity.  By  them  you  take  surgery 
out  of  the  region  of  chance  and  make  it  much  more  an  exact  science.  If  you  happen  to 
have  an  Infectious  case,  let  me  impress  upon  you,  gentlemen,  not  to  look  upon  it  as  an  un- 
avoidable accident,  but  recognize  It  as  being  due  to  some  mistake  in  your  chain  of  treat- 
ment, to  be  found  out  and  in  the  future  guarded  against.  None  of  us  are  free  from  mis- 
takes or  accidents  ;  the  best  surgeon  is  he  who  has  the  least  number,  who  recognizes  that 
he  is  not  infallible,  but  strives  to  discover  his  mistake,  and  from  them  learns  lessons  for  his 
future  guidance. — Dr.  W.  J.  Penny. 


13 


CASE  I. 

tt/ustrating   the  methods  employed  at  Bellevue   Hospital  by  Professor   Stephen 
Smith,  Surgeon  to  Bellevue,  etc. 

/noised  Wound. — A  butcher  cuts  himself  severely  in  the  fleshy  part  of  the 
forearm,  making  a  w^ound  about  five  inches  long.  The  wound  is  deep, 
and  extends  well  down  into  the  muscles  of  the  part.  In  order  to  stop  the 
hemorrhage,  he  had  stuffed  a  dirty  handkerchief  into  the  wound,  holding 
it  in  place  by  means  of  another  rag  tied  around  his  arm.  The  arm  is  dirty 
and  greasy,  and  in  an  excellent  condition  to  cause  suppuration  in  the 
wound  if  the  antiseptic  method  is  not  followed  in  the  treatment. 

TREATMENT. 

In  a  wound  of  this  size  an  aneesthetic  is  usually  necessary  in  order  to 
keep  the  patient  quiet  while  it  is  being  attended  to.  The  whole  arm 
should  be  bared,  the  rags  removed  from  the  wound,  which  should  then  be 
washed  out  thoroughly  with  a  hot  sol.  bichloride,  1-2000,  and  packed  with 
antiseptic  cotton.  The  hands  of  the  surgeon  and  his  assistant  are  first 
rendered  aseptic  by  scrubbing  as  far  as  the  elbow  with  soap  and  water,  and 
immersing  in  sol.  bichloride,  1-1000.  The  instruments  necessary  for  the 
operation  are  placed  in  sol.  ac.  carbolic,  1-30.  The  hand,  forearm  and  arm 
of  the  patient  should  next  be  thoroughly  scrubbed  with  a  hand-brush, 
using  Castile  soap  and  warm  water,  the  parts  far  around  the  woimd  shaved 
with  a  sharp  razor  or  scalpel,  and  then  plentifully  irrigated  with  sol.  bi- 
chloride, 1-2000.  A  rubber  sheet,  which  has  first  been  rendered  antiseptic 
by  being  thoroughly  scrubbed  with  soap  and  water,  and  then  washed  off 
with  sol.  bichloride,  should  be  arranged  for  drainage  into  a  receiving 
vessel.  The  patient's  hand  and  arm  are  enveloped  in  towels,  which  had 
been  soaked  in  sol.  bichloride  1-2000  and  several  carbolized  towels  spread 
under  the  arm  to  receive  instruments  when  laid  down.  A  large  irrigat- 
ing bag  or  pitcher,  filled  with  hot  sol.  bichloride,  1-2000,  should  be  placed 
in  position.  The  antiseptic  cotton  should  now  be  removed  from  the 
wound,  the  spouting  arteries  seized  and  ligated  with  No.  8  prepared  anti- 
septic catgut  and  the  wound  constantly  irrigated  with  the  bichloride  so- 
lution. If  the  radial  or  uLuar  artery  has  been  severed,  each  end  should  be 
ligated  with  prepared  silk  ligatures.  In  closing  the  wound  divided  tissues 
should  be  carefuUy  united  by  sutures  as  nerves,  tendons,  muscles. 
A  prepared  drainage  tube  is  placed  with  one  end  reaching  to  the 
bottom  of  the  wound,  and  the  other  extending  from  its  most  depen- 
dent portion.  Sutures  of  No.  7  prepared  catgut  should  be  used 
to  bring  the  edges  of  the  severed  muscles  together,  and  heavier  prepared 
catgut  to  hold  the  edges  of  the  skin  and  superficial  fascia  in  apposition. 
Iodoform  is  then  dusted  on  the  wound  and  the  dressing  applied  consisting 
of  a  thick  pad  of  iodoform  gauze,  two  inches  wide,  and  an  inch  or  more 


14 

longer  than  the  wound,  a  hole  being  cut  in  one  end  to  admit  of  the  project- 
ing end  of  the  drainage  tube  to  pass  through  ;  a  mass  of  fluffed  bichloride 
gauze  is  placed  over  this,  and  the  whole  forearm  wrapped  with  bichloride 
^auze  padding  ;  this  is  enveloped  in  a  thick  layer  of  absorbent  cotton, 
which  is  retained  in  position  by  several  layers  of  moist  bichloride  gauze 
bandage.  The  first  dressing  should  be  removed  in  about  eight  days,  the 
wound  irrigated  with  sol.  bichloride,  and  a  second  dressing  similar  to  the 
first  applied,  and  allowed  to  remain  an  equal  length  of  time. 


CASE  II. 


Contused  Wound. — A  man  falls,  striking  his  head  upon  the  curb,  and 
sustains  a  severely  contused  scalp  wound  about  three  inches  long,  and  when 
seen  it  is  filled  with  clotted  blood,  hair  and  dirt. 

TREATMENT. 

^Suggested  by  Professor  Lewis  A.  Stimson,  Surgeon  to  Bellevue  Hospital. 

The  hair  should  first  be  clipped  away  for  a  distance  of  an  inch  and  a 
half  all  around  the  wound,  and  after  that  portion  of  the  scalp  has  been 
thoroughly  scrubbed  it  should  be  shaved,  and  irrigated  with  sol.  bichloride, 
1-2000.  The  clot  should  then  be  removed  from  the  wound,  the  ragged 
edges  of  which  should  be  trimmed  away  with  a  scalpel  until  a  fresh  sur- 
face remains.  Care  should  be  taken  to  remove  all  foreign  particles,  espec- 
ially hairs,  from  the  wound,  which  should  be  frequently  irrigated  with 
sol.  bichloride.  Several  strands  of  heavy  prepared  antiseptic  catgut  may 
be  introduced  to  the  bottom,  for  drainage,  if  the  wound  is  deep. 
The  wound  is  then  closed  with  interrupted  sutures  of  No.  7  prepared  cat- 
gut. A  pad  of  iodoform  gauze  is  then  placed  over  the  wound  and  over 
this  a  large  pad  of  moist  bichloride  gauze,  and  the  whole  retained  in  place 
by  a  gauze  bandage.  This  dressing  should  be  removed  and  re -applied 
at  the  end  of  a  week,  unless  the  dressings  become  soiled,  in  which  case  they 
should  be  removed  sooner. 


CASE  III. 


lacerated  and  Contused  Wound. — A  man  is  knocked  down  in  the  street 
and  run  over,  the  wheel  of  the  wae:on  passing  over  his  leg,  without  break- 
ing any  bones,  but  causing  considerable  laceration  of  the  tissues  in  the 
region  of  the  calf,  and  the  wounds  are  filled  with  dirt  and  sand. 


15 


TREATMENT. 

Revised  by  N.  Senn,  M.  D.,  Milwaukee,  Wis.,  Professor  Principles    and  Practice 
of  Surgery  and  Clinical  Surgery,  College  Physicians  and  Surgeons,  Chicago. 

The  patient  should  be  placed  upon  the  operating  table  and  anaesthet- 
ised. The  clothing  should  be  removed  from  the  limb,  which  should  be 
scrubbed  thoroughly  with  potash,  soap  and  water;  the  leg  shaved,  and  then 
irrigated  with  sol.  bichloride,  1-2000.  After  the  surgeon  has  arranged  the 
antiseptic  rubber  sheet  for  drainage,  his  hands  should  be  rendered 
aseptic  ;  and  the  instruments  necessary  for  the  operation  placed  in  sol.  ac. 
carbolic,  1-30.  The  foot  and  thigh  should  be  enveloped  in  carbolized 
towels,  1-30;  several  towels  being  placed  to  receive  instruments  when  laid 
down.  On  making  a  thorough  examination  of  the  wound,  it  is  found  that 
although  the  external  wounds  are  small,  considerable  damage  has  been 
done  to  the  deeper  structures,  and  there  are  several  large  accumulations 
of  blood  in  pockets  extending  in  different  directions.  These  pockets  should 
be  opened  freely  under  constant  irrigation,  and  the  clots  turned  out;  pre- 
pared antiseptic  sponges  being  used  throughout  the  operation.  Large 
antiseptic  rubber  drainage  tubes  should  be  introduced  to  the  bottoms  of  all 
the  pockets,  and  the  edges  of  the  wounds  drawn  together  as  far  as  possible 
by  means  of  prepared  antiseptic  silk  sutures.  The  wound  is  then  dusted 
with  iodoform,  and  an  antiseptic  dressing  applied  as  follows:  A  large  pad 
of  iodoform  gauze  perforated  with  holes  for  the  passage  of  the  ends  of  the 
rubber  drainage  tubes  is  placed  over  the  wound  ;  this  is  covered  with  a 
large  mass  of  dry  bichloride  gauze,  and  the  whole  leg,  from  ankle  to 
knee,  enveloped  with  a  thick  cushion  of  sublimated  mass  ;  over  this, 
place  a  thick  layer  of  absorbent  cotton,  the  whole  dressing  being  held 
in  position  by  means  of  several  layers  of  moist  bichloride  gauze  bandage. 
This  dressing  should  be  left  in  position  until  the  discharge  begins  to 
show  through,  when  it  should  be  renewed.  The  drainage  tubes  should 
remain  in  the  wound  until  there  ceases  to  be  any  discharge  from  the  pock- 
ets. All  subsequent  dressing  should  be  applied  under  the  same  antiseptic 
precautions  as  were  taken  with  the  first. 


CASE  ly. 


Punctured  Wound. — A  boy  falls  upon  a  rusty  nail,  which  makes  a  punc- 
tured wound  two  or  three  inches  deep  on  the  anterior  aspect  of  the  thigh. 
The  blood  has  clotted  over  the  external  opening,  closing  it  entirely. 
There  is  some  inflammatory  swelling  of  the  parts  about  the  wound  due  to 
the  retention  of  the  secretions  in  it. 


16 


TREATMENT. 


Suggested    by    Thomas  G.    Morton,    M.  D.,    Surgeon    to    the   Pennsylvania    and 

Orthopcedic  Hospitals,  Philadelphia. 

The  patient  is  placed  on  a  table  and  anaesthetised  ;  the  whole  limb 
should  be  thoroughly  cleansed  and  irrigated  with  sol.  bichloride,  1-1000; 
and  the  instruments  to  be  used  placed  in  carbolic,  1-30.  After  the  surgeon 
has  rendered  his  hands  perfectly  antiseptic  by  scrubbing,  and  immersion  in 
sol.  bichloride,  1-1000,  the  limb  for  several  inches  above  and  below  the  wound 
should  be  shaved,  the  clot  removed  from  the  wound  and  the  secretions 
allowed  to  escape.  After  the  wound  has  been  thoroughly  irrigated  with  sol. 
bichloride,  the  external  opening  should  be  enlarged  considerably,  and  all 
foreign  particles  carefully  removed.  The  wound  should  then  be  thoroughly 
curretted,  and  perhaps  a  catgut  drain  carried  to  its  bottom,  no  attempt 
being  made  to  close  it,  the  limb  from  the  knee  to  the  groin  covered  with 
moist  bichloride  gauze  padding,  over  this  a  thick  layer  of  absorbent 
cotton  Is  applied,  and  the  whole  held  in  position  by  a  well  applied  band- 
age of  moist  bichloride  gauze. 


CASE  V. 


Compound  Fracture.  — The  patient  has  sustained  a  compound  fracture  of 
the  tibia  and  fibula.  The  projecting  end  of  the  tibia  made  a  small  open- 
ing on  the  anterior  portion  of  the  leg,  about  the  centre.  There  is  consid- 
erable extravasation  of  blood  between  the  fragments  of  bone  and  the  sur- 
rounding tissues. 

TREATMENT. 
Suggested  by  Thomas  G.  Morton,  M.  D. 

The  patient  is  placed  on  the  operating  table  and  anaesthetised,  the 
clothing  is  removed,  and  the  whole  limb  thoroughly  scrubbed  with  soap 
and  water,  and  the  leg  shaved,  an  antiseptic  rubber  sheet  having  been 
arranged  for  drainage.  The  surgeon's  hands  are  rendered  antiseptic  in 
the  usual  manrer  ;  the  mstruments  to  be  used  are  placed  in  carbolic,  1-30. 
The  whole  limb  should  then  be  irrigated  with  sol.  bichloride,  1-1000  ;  and 
the  foot  and  thigh  enveloped  in  1-1000  bichloride  towels ;  several  towels 
being  arranged  under  the  limb  to  receive  instruments  when  laid  down. 
Prepared  antiseptic  sponges  or  little  bunches  of  gauze  should  be  used. 
The  opening  through  which  the  tibia  has  projected  should  be  enlarged 
sufficiently  under  constant  irrigation,  and  the  blood  clots  and  bruised 
tigsues  removed  by  curretting  and  otherwise  ;  the  fragments,  if  necessary, 


17 

are  approximated  and  held  in  position  by  very  strong  chromic  gut  or  pure 
sUver  wire  which  has  been  boiled  and  then  kept  in  sol.  carbolic,  1-20. 
After  thorough  irrigation,  small  prepared  catgut  drains  or  drain- 
age tubes  should  be  introduced  to  the  bottom  of  the  wound,  and  the 
edges  of  the  wound  drawn  together.  The  wound  is  then  to  be  dusted  with 
iodoform,  a  pad  of  bichloride  gauze  applied  over  it,  and  this  in  turn  being 
covered  with  thick  pads  of  moist  bichloride  gauze,  a  thick  layer  of  absorb- 
ent cotton  covers  all,  extending  from  the  toes  to  the  middle  of  the  thigh; 
this  is  held  in  position  by  a  moist  bichloride  gauze  bandage.  The  limb 
should  then  be  placed  in  either  a  fracture  box  or  some  form  of  easily  re- 
movable fixed  dressing.  If  all  goes  well  the  primary  dressing  may  never 
need  replacing;  nevertheless  the  position  of  the  bones  must  be  carefuUy 
guarded  without  disturbing  the  dressings,  if  possible. 


CASE  YI. 


Cold  Abscess. — The  patient  has  a  deep-seated  cold  abscess  on  the  anter- 
ior aspect  of  the  thigh. 

TBEATMENT. 

Suggested  by  Hunter  McGuire,  M.  D.,  L.L.  D.,  Surgeon  to  St.  Luke's  Hospitaf,. 

Richmond,  Va. 

He  should  be  placed  on  the  table  and  ansesthetised,  a  rubber  sheet  ar- 
ranged for  drainage,  the  whole  thigh  thoroughly  scrubbed  and  irrigated 
with  sol.  bichloride,  1-2000;  the  instruments  to  be  used  placed  in  sol.  carbolic, 
1-30.  After  the  surgeon's  hands  have  been  rendered  aseptic  the  skin 
over  the  abscess  should  be  shaved  and  carbolized  towels  used  to  cover  the 
leg  and  upper  portion  of  the  thigh.  Under  constant  irrigation,  a  free 
incision  should  be  made  into  the  abscess  and  its  contents  evacuated.  The 
abscess  cavity  should  then  be  thoroughly  irrigated  with  sol.  bichloride, 
1-2000,  until  the  fluid  which  flows  from  the  cavity  is  as  clear  as  that 
entering  it.  A  couple  of  prepared  antiseptic  drainage  tubes  are  introduced 
into  the  bottom  of  the  abscess  and  secured  in  place  by  safety  pins,  which 
have  been  made  aseptic.  Subiodide  of  bismuth  is  dusted  into  the  wound 
and  a  large  pad  of  carbolated  gauze,  in  which  are  holes  for  the  projecting 
ends  of  the  drainage  tubes,  applied  over  it.  This  is  covered  with  a  large 
mass  of  flujffed  bichloride  gauze,  and  the  whole  covered  with  a  thick  layer 
of  absorbent  cotton,  which  is  held  in  position  by  a  moist  bichloride  gauze 


18 

bandage.  If  the  discharge  from  the  .wound  is  considerable,  it  will  have 
to  be  redressed  every  twenty-four  hours,  and  at  each  dressing  the  abscess 
cavity  should  be  thoroughly  irrigated  with  bichloride,  1-2000. 


CASE  YII. 

Amputat/on. — A  brakeman  has  his  forearm  crushed  between  two  cars. 
The  injury  to  the  bones  and  soft  part  is  so  great  that  amputation  is  con- 
sidered necessary. 

TREATMENT. 

Suggested  by  D.  Hayes  Rgnew,  M.  D.,  L.L.  D.,  Professor  of  Clinical  Surgery  at 
the  University  of  Pennsylvania. 

The  patient  should  be  etherized,  and  the  whole  arm  thoroughly  cleansed 
and  irrigated  with  sol.  bichloride,  1-1000  ;  carbolized  towels  wrapped  about 
the  hand,  forearm  and  shoulder,  leaving  bare  the  portion  of  the  arm 
through  which  the  amputation  is  to  be  done;  the  necessary  instruments 
placed  in  sol.  carbolic,  1-20  ;  andWie  hands  of  the  operator  and  his  assistants 
rendered  thoroughly  antiseptic  before  touching  the  wound  by  scrubbing 
with  hot  water  and  soap,  and  afterwards  washing  in  a  solution  of  bichlo- 
ride, 1-2000.  The  operation  should  be  done  under  constant  irrigation  with 
sol.  bichloride,  1-2000  ;  the  arteries  ligated  with  No.  7  prepared  catgut. 
Silk  worm  gut,  or  silver  wire,  for  suturing  the  flaps  ;  prepared  rubber 
drainage  tubes  being  employed  for  drainage.  Don't  use  bone  ;  they  will 
collapse  and  fail  to  drain.  Prepared  antiseptic  sponges  should  be  used 
throughout  the  operation.  The  wound,  after  being  dusted  with  iodoform, 
should  be  covered  with  oil  silk  protective,  which  should  be  perforated 
with  holes  for  the  passage  of  the  exposed  ends  of  the  drainage  tubes. 
Cover  this  with  either  a  pad  of  moist  bichloride  gauze  or  carbolized  gauze, 
over  which  place  a  second  dry  pad  of  the  same  material,  and  lastly,  a  layer 
of  absorbent  cotton,  and  secure  with  bichloride  or  carbolized  roller  band- 
age. The  dressing  should  be  removed  under  the  same  antiseptic  precau- 
tions as  soon  as  the  discharges  show  through  or  the  temperature  rises. 


19 


CASE  Vlll. 

Illustrating  the  antiseptic  method  of  treating  burns  and  scalds,  suggested  by  S.  W. 
Gross,  M.  D.,  L.L.D.,  Professor  of  the  Principles  of  Surgery  and  Clinical  Surgery 
in  the  Jefferson  Medical  College,  Philadelphia 

Burn. — A  boy  of  twelve  upsets  a  kettle  and  bums  the  left  leg  from 
knee  to  ankle  with,  boiling  water. 

TREATMENT.     ' 

By  far  the  most  efficient  and  painless  method  of  managing  burns  and 
scalds,  is  that  practiced  by  Mosetig-Moorhof,  and  it  is  the  one  which  I  in- 
variably employ.  The  vesicles  having  been  opened  and  excised,  the  en- 
tire burned  surface  is  smoothly  covered  with  dry  compresses  of  20  per 
cent,  iodoform  gauze,  over  which  gutta  percha  tissue  is  placed.  The 
whole  is  then  surrounded  by  a  thick  layer  of  sterilized  absorbent  cotton 
between  layers  of  corrosive  gauze,  "which  is  secured  by  a  roller  with  a 
moderate  degree  of  pressure.  Such  a  dressing  rapidly  relieves  pain,  pre- 
vents contact  of  air  and  infection  by  septic  pus,  and  by  its  inf requency 
keeps  the  part  at  rest.  It  should  be  allowed  to  remain  from  7  to  14  days. 
In  burns  of  the  second  degree,  one  dressing  sufiBces.  In  the  worst  burns 
there  is  relatively  little  suppuration,  and  the  eschars  thrown  off  are 
aseptic. 

For  bums  of  the  face  iodoform  ointment  (1  part  iodoform,  vaseline 
20  parts)  is  used,  and  covered  with  a  gutta  percha  tissue  mask.  The  oint- 
ment should  be  renewed  daily. 

The  Bellevue  Hospital  Method  of  Treating  Burns 

Is  ordinarily  as  follows  :  After  the  usual  antiseptic  precautions,  such 
as  irrigation  with  1-2000  bichloride  solution,  etc.,  and  removing  all  the  cu- 
ticle covering  the  wound,  the  burned  surface  is  covered  with  sheet  lint, 
on  which  has  been  spread  an  ointment,  iodoform  and  sub-nitrate  of 
bismuth  each  1  part,  vaseline  20  parts.  Bichloride  gauze  and  absorbent 
cotton  are  then  applied  over  this,  as  described  above. 


CASE  IX. 

Jllustrating  the  Method  of  Using  Antiseptics,  Practiced  by  Prof.  A.  C.    Bernays, 

of  St.  Louis,  Mo. 

A  workman  in  a  stamping  shop  is  brought  to  the  surgeon's  office, 
having  all  the  fingers  of  his  left  hand  crushed  and  also  the  heads  of  the 
lour  metacarpal  bones.     The  hand  is  black  from  the  factory  dust  and  soot; 


20 

the  wound  not  bleeding  much,  has  been  tied  up  hurriedly  by  a  fellow- 
workman  with  a  dirty  handkerchief. 

The  first  thing  done  is  the  preparation  of  a  warm  solution  of  bichloride 
1-1000,  into  which  the  hand  is  immersed,  and  where  it  is  left  for  a  few 
minutes,  until  one  may  safely  assume  that  the  solution  has  penetrated  alL 
the  spaces  of  the  lacerated  wound.  Next  the  forearm,  wrist  and  hand  ai*e 
thoroughly  washed  with  soap  and  a  brush,  using  the  -warm  bichloride  water. 
While  the  now  soapy  and  dirty  water  is  allowed  to  run  down  the  waste- 
pipe  of  the  wash  basin,  and  another  bichloride  solution  1-2000  is  being  pre- 
pared and  other  preparations  for  the  operation  and  dressing  are  being 
made,  the  hand  is  kept  enveloped  in  a  towel  wet  with  bichloride  solution. 

The  patient  is  now  placed  on  the  operating  table  and  is  chloroformed- 
The  Esmarch  bandage  is  applied  over  the  towel  which  covers  the  injured- 
band  aud  the  tourniquet  fastened  just  above  the  elbow.  The  wet  towel  is 
next  removed  from  the  crushed  hand  and  the  necessary  operation  is  per- 
formed while  a  stream  of  bichloride  is  constantly  running  over  the  field  of 
operation.  All  visible  arteries  are  tied  with  silk  ligatures.  The  Esmarch 
tourniquet  is  loosened  and  the  wound  constantly  irrigated  until  all 
hemorrhage  ceases  and  during  the  application  of  the  numerous  skin 
sutares.  Since  the  flaps  can  be  accurately  approximated  and  drawn  to- 
gether so  as  to  scarcely  leave  a  cavity  at  all,  the  drainage  tube  is  dispensed 
with  and  the  whole  wound  united  by  sutures  so  as  to  leave  no  spot 
uncovered  by  skin.  A  piece  of  the  gauze  about  six  inches  long  is  un- 
rolled, and  this  layer,  composed  of  eight  thicknesses,  is  accurately 
adapted  to  the  line  of  suture  and  is  fastened  by  a  bichloride  gauze  bandage. 
Over  this  is  placed  a  thick  layer  of  absorbent  cotton  which  extends  just 
above  the  wrist,  and  over  this,  finally,  a  double  layer  of  the  moist  parch- 
ment dressing  paper  is  adjusted  so  as  to  hermetically  seal  the  whole  dress- 
ing two  inches  above  the  wrist  by  means  of  a  bandage.  This  ends  the 
antiseptic  dressing,  but  let  it  be  borne  in  mind  that  this  is  not  sufficient, 
for  we  must  now  fulfill  an  indication  which  is  of  paramount  importance 
with  the  antiseptic  indication.  "We  must  place  the  injured  limb  in  a  splint, 
v^i^hich  insures  physiological  and  mechanical  rest  to  the  injured  parts,  since 
it  is  certain  that  without  this  precaution  our  antiseptic  dressing  would 
not  prevent  painful  swelling  and  suppuration.  This  point  has  been  some- 
what crowded  into  the  background  by  so^ne  of  the  enthusiastic  antisep- 
ticists,  and  we  desire  most  especially  to  emphasize  it  in  this  connection,  in 
this  "  Epitome  of  Antiseptic  Surgery."  It  is  through  neglect  of  this  indi- 
cation that  great  harm  has  been  done  by  some  who  overlooked  it  because 
of  their  blind  faith  in  the  antiseptic  panacea. 

The  patient  is  removed  to  his  home  with  instructions  to  take  a  ^  gr. 
of  morphine  at  bedtime,  if  necessary,  to  stop  pain,  and  to  present  himself 
at  the  surgeon's  office  the  next  morning.  There  being  no  pain  and  no  ele- 
vation of  temperature,  the  patient  sleeping  well  and  having  a  good  appe- 
tite, the  injured  limb  is  left  alone.  On  the  10th  day  there  is  a  smell  per- 
ceptible and  the  patient  has  no  pain,  but  feels  a  sort  of  itching  in  his  hand. 


21 

On  removal  of  the  dressing  the  whole  wound  is  united,  excepting  about 
one  square  inch  of  the  baU  of  the  little  finger,  where  a  black  gangrenous 
piece  of  skin  is  found  ready  to  drop  off,  the  line  of  demarcation  having 
been  completely  formed.  At  the  time  of  the  operation  this  piece  of  skin 
seemed  to  be  living,  in  fact  it  was  thought  that  unusually  good  flaps  had 
been  secured.  Under  the  antiseptic  dressing  the  secretion  attending  the  se- 
questration of  the  dead  piece  of  skin  and  fascia  had  been  taken  up  by  the 
absorbent  dressing  and  no  symptom  of  fever  or  suppuration  had  ever  been 
noticeable.  This  could  never  take  place  under  a  so-called  diy  antiseptic 
dressing,  because  the  dry  dressings  rapidly  become  hard  and  their  absor- 
bent qualities  are  rendered  purely  illusory.  The  dressing  used  in  this  case 
formed  a  moist  chamber  around  the  wound  in  which  an  even  temperature 
and  an  evenly  distributed  antiseptic  vapor  was  constantly  present.  This 
explains  the  possibility  of  maintaining  an  absorbent  dressing  for  many 
days  by  the  moist  method  and  also  demonstrates  the  advantages  of  the 
latter  in  certain  cases  over  the  dry  dressing. 

After  the  sutures  were  removed  a  moist  antiseptic  dressing  was  reap- 
plied daily  and  the  granulating  surface  allowed  to  heal,  which  it  rapidly 
did.     The  patient  was  discharged  on  the  twenty-sixth  day  cured. 

For  simplicity,  as  well  as  efiiciency,  it  is  beHeved  that  this  method  is 
unsurpassed.  It  has  been  tried  in  hundreds  of  cases  with  but  slight  modi- 
fications to  suit  the  exigencies  arising  from  the  different  anatomical  rela- 
tions of  the  injured  parts.  The  successes  achieved  are  equal  to  the  highest 
reported  by  any  author,  and  comprise  the  entire  domain  of  surgery,  as  it 
presents  itself  to  a  busy  surgeon  in  metropolitan,  private  and  hospital 
serrice.  The  method  deserves  the  notice  of  all  practitioners  of  medicine 
as  one  of  the  many  modifications  of  the  antiseptic  system  of  treating 
wounds. 

Small  Wounds  and  Abrasions. 

Dr.  Bernays  suggests  that  in  small  wounds  and  abrasions,  and  the  so- 
called  runarounds  and  felons,  a  simple  antiseptic  dressing  is  quite  as  much 
in  place  as  in  very  large  and  serious  wounds.  The  dressing  should  consist 
•of  several  thicknesses  of  bichloride  gauze,  which  may  be  held  in  place  by 
xubber  adhesive  plaster. 


CASE  X. 


An  Antiseptic  Amputation  of  the  Thigh  after  a  Railroad  Crush — Method  in  use  at  the 
University,  Philadelphia,  and  German  Hospitals,  by  Prof.  J.  Wm  White,  Phila- 
delphia. 

Look  after  the  general  condition  of  the  patient.     Give  stimulants  in 
small  doses,  if  necessary,  and  see  that  all  hemorrhage  is  arrested  by  a 


22 

tourniquet  or  an  Esmarch's  bandage  applied  just  below  the  groin.    After 
this,  proceed  as  follows  : 

1.  Wash  over  the  whole  limb,  first  shaved  clean,  (a)  with  soap  and 
water,  (&)  with  alcohol,  turpentine  or  ether,  and  (c)  veith  1-500  bichloride 
solution.  The  wround  and  crushed  area  raay,  with  advantage,  be  washed 
with  a  chloride  of  zinc  solution  of  10  to  20  grs.  to  the  ounce.  These 
measures  are  especially  necessary  in  such  cases  on  account  of  the  dirt 
ground  into  the  recesses  of  the  tissues. 

2.  Cover  the  bed  with  a  rubber  cloth  wet  with  1-500  bichloride  solu- 
tion, and  encircle  the  sound  part  of  the  limb  and  all  portions  of  the 
crushed  regions  with  towels  vret  with  1-1000  bichloride  or  1-20  carbolic 
solution. 

3.  Use  only  instruments  which  have  been  boiled  after  last  use  and 
have  been  lying  in  1-20  carbolic  solution  not  less  than  fifteen  minutes. 

4.  During  the  operation  a  stream  of  1-1000  sublimate  solution,  as 
nearly  continuous  as  possible,  is  kept  dripping  on  the  wound. 

5.  Tie  everything  with  catgut.  Use  rubber  drainage  tubes  taken 
direct  from  bichloride  or  carbolic  solution  and  put  in  place  while  dripping. 
Sew  with  catgut,  or  silver  wire,  or  silkworm  gut,  but  in  either  case  the 
suture  material  must  be  taken  direct  from  the  antiseptic  solution. 

6.  Dress  with  (a)  protective  over  the  line  of  wound,  (&)  iodofonn  on 
whole  stump,  (c)  wet  dressing  of  at  least  eight  layers  sublimate  gauze, 
(d)  moist  dressing  with  iodoform  over  inner  surface,  (e)  salicylic  or  sub- 
limate cotton,  (/)  gauze  bandage. 


Antiseptic  Dressings. 

The  importance  of  reliable  dressings  cannot  be  overestimated.  With- 
out these  all  the  surgeon's  skill  is  wasted.  Joseph  Lister  prepared  his 
own  dressings,  using  as  a  base  for  the  antiseptic  a  compound  of  resin, 
lard  and  paraffine.  Into  a  hot  solution  of  this  compound  was  dipped  un- 
bleached non-hygroscopic  gauze. 

So  long  as  the  Lister  method  was  confined  to  large  hospitals,  and  the 
dressings  so  made  were  quickly  used,  they  partially  fulfilled  antiseptic 
requirements,  but  were  at  best  harsh,  stiff,  non-absorbent  and  unsatis- 
factory. 

With  a  little  age  they  became  more  or  less  inert  and  unreliable. 

Dressings  are  still  prepared  as  above  by  nearly  all  manufacturers. 


23 


Union  Moist  Dressings. 


The  dressings  now  used  by  our  leading  surgeons  and  large  hospitals 
differ  from  those  prepared  by  the  Lister  method  in  many  important  par- 
ticulars. 

We  have  mainly  followed  the  methods  adopted  at  Bellevue  and  other 
New  York  hospitals,  with  the  improvements  suggested  by  Dr.  A.  C.  Ber- 
nays,  of  St.  Louis,  Dr.  S.  W.  Gross,  of  Philadelphia,  and  others. 

Experience  has  shown  that  the  best  dressings  should  possess  the  fol- 
lowing characteristics  : 

1st.  They  must  be  aseptic  or  sterilized. 

2d.  Absorptive  and  moist. 

3d.  Soft  and  pliable. 

4th.  So  prepared  that  the  antiseptic  used  shall  be  of  known  strength. 
Each  pound  of  cotton,  fabric  or  solution  shall  contain  an  exact  measure 
of  the  antiseptic  drug. 

Says  Dr.  Bemays  ;  "  Besides  the  mechanical  improvement  in  being 
absorptive,  flexible,  etc.,  moist  dressings,  where  properly  applied  to  a 
wound  (iinder  impermeable  covering,  such  as  Linton  Dressing,  paper,  or 
gutta  percha  tissue),  are  vaporized  in  the  chamber  so  formed  by  the  tem- 
perature, and  cause  an  evenly  distributed  antiseptic  vapor  about  the 
wound." 

A  recent  observer,  Schlange,  of  Berlin,  has  developed  the  fact  that 
defects  of  no  mean  order  are  to  be  met  with  in  our  supposed  aseptic  sub- 
limate dressings.  He  has  proven  after  examination  that  all  dry  anti- 
septic bandage  materials  contain,  without  exception,  more  or  less  micro- 
organisms which  are  capable  of  liquefying  gelatine — i.  e.,  producing 
putrefaction  ;  but  that  recently  prepared  moist  gauze,  or  gauze  that  has 
been  rendered  sterile  by  heat  or  boiling  water,  can  be  considered  free  from 
germs. 

Professor  Robert  F.  Weir  says,  referring  to  bichloride  gauze  : 

"  Unless  it  is  carefully  kept  in  a  damp  condition,  and  properly 
wrapped  up  ia  an  impermeable  wrapper,  such  as  rubber  or  gutta  percha 
tissue,  the  bichloride  will  soon  become  changed  into  the  comparatively 
inert  calomel.  In  fact,  even  in  quite  freshly  made  but  dry  gauze,  a  large 
quantity  of  calomel  will  soon  be  found,  and  this  and  the  remaining 
bichloride  can  perceptibly  be  shaken  out  of  it ;  also,  germs  find  a  lodg- 
ment in  the  dry  gauze.  By  chemical  tests  I  have  found  that  well-pre- 
served damp  gauze  had  not  appreciably  changed  its  strength  one  month 
after  its  manufacture." — Med.  News. 

In  preparing  Linton  moist  gauzes  or  cotton,  the  following  method  is 
used,  except  where  the  drug  is  not  soluble  in  solution  of  water  and 
glycerine  : 

1st.  Boil  the  fabric  or  fibre  under  steam  pressure  until  the  tempera- 
ture is  raised  to  250  deg. 


24 

2d.  The  antiseptic  solution  is  prepared  with,  distilled  water,  to  which 
is  added  the  antiseptic  to  be  employed,  together  with  10  per  cent, 
of  pure  glycerine.  The  glycerine  is  added  for  the  double  purpose  of  keep- 
ing the  dressing  moist  and  of  preventing  crystallization  of  the  drug. 

3d.  The  temperature  of  the  solution  is  then  raised  to  the  boiling  point 
and  the  dressing  is  then  dipped  in.  After  removing  the  dressing  the  ex- 
cess over  the  required  amount  of  the  solution  is  extracted  by  a  machine 
specially  adapted  to  the  purpose. 

4th.  While  still  hot,  the  dressing  is  carefully  wrapped  in  an  impermea- 
ble cover. 

In  preparing  corrosive  sublimate  dressing,  distilled  water  is  a  necessity 
to  prevent  any  precipitation  or  change  of  the  mercury.  As  an  additional 
precaution,  to  prevent  chemical  change,  tartaric  acid  is  used  to  make  the 
solution  complete  and  permanent. 

The  preparation  of  iodoform  gauze  is  attended  with  some  difficulties, 
owing  to  the  insolubility  of  iodoform.  Our  method  is  to  take  gauze  of 
known  weight,  previously  soaked  in  solution  corrosive  sublimate  1  to  5000. 
Carefully  mix  the  percentage  of  iodoform  to  be  used  with  glycerine  in  a 
paste.  Scrape  this  over  the  gauze  until  the  iodoform  is  evenly  distributed. 
Iodized  cotton  we  prepare  by  placing  absorbent  cotton  and  iodine  in  an 
enclosed  vessel  and  vaporizing  the  iodine  by  heat. 

JOHNSON  &  JOHNSON. 


25 


SURGEON'S  ANTISEPTIC  DRESSING  CASE. 

AS  SUGGESTED  BY  PROP.   S.   W.   GROSS. 


Containing  420  grs.  carbolic  acid  in  a  bottle,  s.  add  tol  quart  water  for 
Z  per  cent,  solution.  (For  instruments. )  Tablets  of  corrosive  sublimate, 
7.5grs.  in  eacb;  Ammonium  chloride,  7.5  grs.  in  each;  1  tablet  to  pint  of 
water,  equal  to  1-1000  solution.  5  yards  bichloride  gauze.  1  yard  iodo- 
form gauze,  20  per  cent.  1  yard  adhesive  iodoform  gauze,  20  per  cent. 
3^  lb.  absorbent  cotton.  6  prepared  natural  sponges.  3  roller  bandages, 
2, 23^,  3  inch.,  8 yds  long.  1  yard  dressing  paper.  1  bottle,  3  sizes,  catgut 
ligatures.  1  bottle,  3  sizes,  silk  sutures.  1  bottle,  3  sizes,  chromicized 
catgut  sutures  (after  Macewen's  formula),  10  feet.  6  drainage  tubes  (red 
rubber  or  glass).  }/^  oz.  iodoform,  in  a  hard  rubber  sprinkler.  1  razor.  1 
nailbrush.  1  yard  gray  rubber  cloth  (to  put  under  part  operated  on,  to 
keep  things  dry).  1  cake  of  soap.  1  f  ountaiu  syringe.  1  three  oz.  hard 
rubber  syringe,  with  different  nozzles.  2  oz.  bottle,  10  per  cent,  iodoform 
collodion.  1  large  camel's  hair  pencil.  5  yds  1  inch  rubber  adhesive 
plaster.  In  a  neat  polished  mahogany  case,  with  metal  handle  for  carrying. 

Special  prices  will  be  quoted  for  cases  containing  assortments  of 
articles  differing  from  the  above. 

JOHNSON   &  JOHNSON,  25  Cedar  Street,  New  York. 


PRICE   LIST. 


Johnson  6^  Johnson, 

NEW    YORK. 


The  following  List  contains  only  the  most  important  of  the 
articles  manufactured  and  sold  by  us.  Our  complete  List  will 
be  found  to  embrace  all  varieties  of  Surgical  Dressings  and 
Medicinal  Plasters.  ' 


BANDAGES. 

ADHESIVE. — Adheres  to  itself  but  not  to  the  skin. 

\  in.  X  10  yds,  per  roll    $     .50 

1  in.  X  10  yds,  per  roll  .60 

2  in.  X  10  yds,  per  roll  .75 

COTTON.— Strong,  Assorted  Sizes,  1^  to  3^  in.  per  lb.  .75 
GAUZE. — Linton,  Moist,  Carbolated  5  percent..  Sublimated  1-2000. 

2  in.  X  10  yds,  per  doz.  1.50 

3  in.  X  10  yds,  per  doz.  1.80 

4  in.  X  10  yds,  per  doz.  2.25 

GAUZE. — Linton,  Moist  lodofoma  10  per  cent. 

2  in.  X  10  yds,  per  doz.  2.50 

3  in.  X  10  yds,  per  doz.  3.00 

4  in.  X  10  yds,  per  doz.  3.75 
PLASTER  PARIS. 

1^  in.  X  5  yds,  per  doz.  1.50 

2  in.  X  5  yds,  per  doz.  1.60 

3  in.  X  5  yds,  per  doz.  1,80 

4  in.  X  5  yds,  per  doz.  2.00 

ESM ARCH'S  RUBBER.— PMri&ed  Gum,  Assorted,  2  to  3  in.    $1.25  to  2.25 


27 
PRICE  LIST— JOHNSON  &  JOHNSON— NEW  YORK 

COTTONS. 


Our  plain  Absorbent  Cotton  is  prepared  in  continuous  layers,  rolled  with 
tissue  paper  between  them,  to  keep  the  cotton  from  feltinp.  By  this 
method  the  cotton  is  furnished  in  even,  flat  layers,  the  convenience  of  which 
may  be  seen  at  a  glance. 

PLAIN--ABSORBENT Dry. 

BORA  TED.  -Absorbent Moist. 

CARB0LATED.—Ah?.OTheB.t Moist. 

CORROSIVE  5(/5.— Absorbent Moist. 

/0/7/ZfZ7.— Absorbent Dry. 

IODOFORM  —Absorbent Moist. 

5 rr/T/C- Absorbent .  ..Moist. 

SALICYLA  r£^.— Absorbent Moist. 

All  rolled  in  thin  layers.     The  above  are  also  put  up  in 
^,  I,  I,  and  ^  lb.  packages. 


Per  lb. 

.60 

10  per  cent. 

Per  lb. 

.75 

5  per  cent. 

Per  lb. 

.75 

1  to  2000. 

Per  lb. 

.75 

7^  per  cent. 

Per  oz. 

.25 

10  per  cent. 

Per  oz. 

.25 

Per  oz. 

.25 

10  per  cent. 

Per  lb. 

.90 

GAUZE.     Linton,  Moist,  Antiseptic. 


Wrapped  in  impermeable  covering,  and  packed  in  sealed  tin 

cans. 

CARBOLA  TED 5  per  cent.  1x5  yds. 

CORROSIVE  SUB.  1  to  2000.     1x5  yds. 
EUCALYPTOL. . .  .10  per  cent.  1x5  yds. 

IODOFORM 10  per  cent.  1x5  yds. 

IODOFORM 20  per  cent.  1x5  yds. 

IODOFORM 50  per  cent.  1  x  5  yds. 

NAPTH ALINE.  . .  .10  per  cent.  1x5  yds. 
THYMOL 10  per  cent.  1x5  yds. 

IODOFORM  SPRINKLERS. 

HARD  RUBBER,  each 1.00 

IODOFORM  OINTMENT 

IODOFORM  COLLODION 


Per  roll. . 

.75 

sq.  yd 

.  .20" 

Per  roll. . 

.75 

.20' 

Per  roll. . 

.90 

.25 

PerroU.. 

l.BO 

.30 

Per  roll.. 

,   1.75 

.40 

Per  roll.. 

,  3.00 

.70 

Per  roll. . 

,     .90 

25 

Per  roll.. 

.     .90 

.25 

28 


PRICE  LIST— JOHNSON  &  JOHNSON— NEW  YORK. 


LINTON  COMBINED  DRESSING. 

(Absorbent  Cotton  and  Gauze,  as  shown  in  illustration,)  A  sub- 
stitute for  both.  Can  be  famished  any  width  or  length  re- 
quired.    See  page  8. 


PLAIN,  Dry per  lb.  .90 

MOIST,  Carbol'd 5 per  ct.  or  Bich.  1  to  2000,  3  in,  x  10  yds,  per  lb.  1. 00 

"            "            "           "        "    4  in.  X 10  yds,  per  lb.  1,00 
Special  prices  for  25  and  50  yard  rolls,  15  inches  wide. 


JUTE. 


PLAIN ..      Per  lb. 

CARBOLA  TEO.     5  per  cent.      Per  lb. 
TARRED Per  lb. 


.35 

.40 
.45 


29 


PRICE  LIST— JOHNSON  &  JOHNSON— NEW  YORK. 


LIGATURES. 


SILK  WORM  GUT. 


CA  TGU  T.     Raw,  per  bundle 1.00' 

"  Aseptic.  Three  spools  on  wire 
frame  in  each  bottle.  Assorted  sizes, 
Nos.  1,  2  and  3,  in  oil  juniper  or  a 
sublimate  solution  made  "with  alcohol. 
Also,  Chromized  (Macewen's  Process). 

Per  bottle 1.00 

Note  — The  experience  of  the  ma- 
jority of  surgeons  is  in  favor  of 
juniper  oil  or  alcohol  for  preserving 
catgut.  For  description  of  our  method 
of  preparing  catgut  see  page  9. 
SILK,  Aseptic.  Three  spools  on  wire 
frame  in  each  bottle.  Assorted  sizes. 
Carbolated  or  Sublimated.    Per  bottle,  .75 

Raw    Chinese,    twisted    and    iron 
dyed,  4  sizes,  on  boards,  each .10 

Raw  Chinese,  braided,  four  sizes, 

on  boards.    White,  each .85 

Iron  dyed,  each =  .30 

Per  bundle 1.35 


LINT. 


Perfect  Absorbent,  in  pound  roUs,  per  lb 

Prepared  by  J.  W.  Johnson's  patent  process. 

MACKINTOSH  CLOTH.      Am.     Per   yard 

MUSLIN,  OILED.     Boxes.     Per  yard 

OAKUM.     Pound  boxes.     Per  pound 


.7^ 

1.00- 

.35 


PAPER. 


LINTON  MOIST.     Carbolated,  1  yd.  x  5  yds,  per  roll 

A  strong,  flexible,  impervious  parchment  paper.  A  good  substitute  for  Oil 
SUk,  Mackintosh  Cloth,  or  Qutta  Percha  Tissue.  Some  surgeons  con- 
sider it  preferable  to  all  these. 


.7& 


PAPOID Per  Ounce,  |3.50 

PAPOID  AND  SODA    TABLETS "     100,  1.50 

PAPOID  AND  BORACIC   TABLETS. "     100,  1.50 

PAPOID  PILLS,   1  GRAIN,  Compressed "     100,  1.50 

"            "       «'       '<        Gelatine  coated "    100,  1.50 


30 


PRICE  LIST— JOHNSON  &  JOHNSON— NEW  YORK. 


PLASTERS. 

Prepared  witli  Boracic  or  Salicylic  Acid  in  the  mass. 

Medicated  plasters  should  not  be  perforated,  as  shown  by  Dr.  Unna,  where 
absorption  of  an  incorporated  drug  is  expected.  The  rubber  mass  con- 
stitutes an  impermeable  back,  which  retains  the  moisture  generated  be- 
neath the  plaster.  The  moisture  thus  retained  dissolves  the  drugs  and 
in  turn  softens  the  homy  layers  of  the  skin,  thus  facilitating  absorp- 
tion, which  isfurther  aided  by  the  addition  of  boracic  or  salicylic  acid 
to  the  mass. 

ACONITE  AND  BELLADONNA.      7  in.  x  1  yd.     Per  yd 

AMMONIAC  AND  MERCURY,  U.  S.  P.     7  in.  x  1  yd.      Per  yd 

BELLADONNA  WITH  BORACIC  ACID. 

Ext.  Belladonna,  18  per  cent. ;  Adhesive  Mass,  73  per  cent. ;  Boracic  Acid, 
10  per  cent.    The  Extract  Belladonna  used  contains  4-4  per  ct.  Atropia. 
7  in.  X  1  yd.      Per  yd 

BLISTERING.     (Cantharidal).     7  in.  x  1  yd.     Per  yd 

CAPSICUM.     7  in.  X  1  yd.     Per  yd 

MERCURIAL.    (Mercury  &  Chalk).     7  in.  x  1  yd.     Per  yd. 

MUSTARD.     6in.  xlyd.     Per  yd 

MUSTARD  LEAVES.  10  in  box.     Per  box 

OPIUM,  U.S.  P.     7  in.  xlyd.     Per  yd 

RUBBER  ADHESIVE.     On  Hollow  Cylinders. 

f 


.70 
1.00 


.75 
.75 
.70 
.75 
.25 
.35 
.75 


The  convenience  of  Rubber  Adhesive  Plaster  Tapes,  on  hollow  cylin- 
ders, is  shown  by  the  above  illustration. 


31 

PRICE  LIST— JOHNSON  &  JOHNSON— NEW  YORK. 

PLASTERS. 

RUBBER  ADHESIVE. 

I  in.  X  5  yds.     Per  roll,  on  hollow  cylinders. .  .15 

1  in.  X  5  yds.     Per  roU,      "            "                ...  .25 

2  in.  X  5  yds.  Per  roll,  "  "  ...  .40 
Sin.  X  5  yds.  Per  roll,  "  "  ...  .60 
7  in.  X  1  yd.    In  box,  each .30 

SURGEON'S  SILK,  Isinglass.     7  in.  x  1  yd.    Per  yd 50 

SURGEON'S  MUSLIN,  Isinglass.     8  in.  x  1  yd.    Per  yd 40 

THAPSIA.     12|^  per  cent  Resin  Thapsia.    Per  yd .70 

RUBBER. 

CLOTH.     Per  yard 1.00 

S/L/C. 

OILED.     28  in.  X  1yd.     Per  yard 1.00 

"         Lister's  Protective.    Per  yard 1.25 

SPONGES. 


LINTON  MOIST.  Aseptic  plain,  doz. 
"  "       Carbolated  10    per 

cent,  doz 

"            "       Corrosive  Sub,  1  to 
1000 


T/SSUE. 

GUTTA  PERCH  A,  heavy,  per  yard 

"  "  "         light,  per  yard. 


.55 


.70 


.70 


.65 
.50 


32 


PRICE  LIST— JOHNSON  &  JOHNSON— NEW  YORK. 


TABLETS. 


AN  T/SEP  TIC.  —  Corrosive  Sub. , 
gr.  7.5;  Ammonium  Chlor- 
ide, gr.  7.5.  Prepared  so  that 
1  Tablet  to  1  pint  of  water 
equals  Solution  1  to  1000. 
By  increasing  or  diminish- 
ing the  amount  of  water, 
the  strength  of  the  solution 
may  be  altered  at  pleasure. 
For  example: 

1  Tablet  to  Oss  =  1  in  500. 
1  Tablet  to  Oj  -1  in  1000. 
1  Tablet  to  Ojss=l  in  1500. 
1  Tablet  to  Oij  =1  in  2000. 
1  Tablet  to  Oiij  =1  in  3000. 
1  Tablet  to  Ov  r^l  in  5000. 
1  Tablet  to  Ox  ^1  in  10000. 
Per  bottle,  containing  25. . . . 


.35 


Per  dozen 3.00 

Dr.   Bernays'   formula,  Corrosive  Sublimate,  gr.    7; 
Citric  Acid,  gr.  3.48;  1  tablet  to  1  pint  of  water, 

makes  a  solution  of  1-1000.    Per  bottle 35 

Per  dozen 3.00 

TAMPONS. 

UNTON  MO/ST.— BoroGljceride,   10  per  cent.      Per 

doz 1.20 

Belladonna,  5  per  cent.     Per  doz 1.20 

Eucalyptine,  5  per  cent.     Per  doz 1.20 

Iodine,  5  per  cent.     Per  doz 1.20 

Pinus  Canadensis,  7^  per  cent.    Per  doz 1.20 


TUBES. 


50 


/?/?/l/yV4<?£.— Decalcified  Bone  each 

Purified  Rubber,  5  sizes  in  each  bottle,  in  Carbol- 

ized  Solution  5  per  cent.     Per  bottle 1.00 

Glass  Drains,  7  sizes,  each 

At  the  suggestion  of  Prof.  S.  W.  Gross,  we  have  recently  had  made 
for  U3  seven  sizes  of  Glass  Tubes,  which  vary  in  length  from  two 
and  one  half  inches  to  five  inches,  and  in  diameter  from  seven  to 
ten  millimeters,  with  openings  one-third  the  diameter  of  the  tube, 
which  are  ovoidal,  with  perfectly  smooth  edges,  and  which  are 
placed  one-half  an  inch  apart.  One  end  of  each  tube  is  provided 
with  two  smaller  openings,  for  the  insertion  of  a  safety  pin.  A 
munber  of  authorities  state  that  these  tubes  are  preferable  to  any 
they  have  ever  seen. 


IVOGL. 

Z.^Af5'5—A septic,  per  lb. 


f  'Z^^^ 


i!   I 


2.50 


33 


On  the  Action  of  Papoid  in  the  Treatment  of  Dyspepsia 
and  Diphtheria  —  Recent  Experiments,  Notes  and 
Comments. 

In  response  to  many  inquiries  from  the  profession  regarding  the  na- 
ture of  the  Carica  Papaya,  from  which  Papoid  is  made,  we  print  the 
followmg  from  Ohaviber's  Encyclopcedia,  Vol.  6,  page  52 : 

"  CARICA  PAPAYA.— A  South  American  tree  of  the  natural 
order  Papayacia — of  which  about  thirty  species  are  known — which 
has  been  introduced  into  many  tropical  countries.  It  grows  to  the  height 
of  fifteen  to  thirty  feet,  with  leaves  only  at  the  top,  where,  also,  the  fruit 
grows  close  to  the  stem.  Leaves  grow  twenty  to  thirty  inches  long. 
The  fruit  is  of  green  color,  very  similar  in  appearence 
to  a  small  melon,  and  with  a  somewhat  similar  flavor. 
It  is  eaten  raw  or  boiled.  The  seeds  are  round  and 
Fruit  of  the  Carica  black,  and  when  chewed  have  in  a  high  degree  the  pun- 
Papaya.  gency  of  powdered  cresses.     The  powdered  seeds  and 

the  unripe  fruit  are  most  powerful  anthelmintics.  The  milky  juice  of  the 
tree  is  very  acrid.  The  leaves  are  used  by  the  negroes  instead  of  soap 
to  wash  linen.  The  juice  and  fruit  of  the  tree  have  the  singular 
property  of  rendering  the  toughest  beef  tender  in  a  short  time.  Even  the 
exhalations  of  the  tree  have  this  property,  and  joints  of  meat,  fowl,  etc., 
are  hung  among  its  branches  to  prepare  them  for  the  table.  It  is  a  tree  of 
exceedingly  rapid  growth,  bears  fruit  all  the  year,  and  is  extremely  pro- 
lific. It  is  cooked  in  various  ways.  The  Chambura  (C-digita),  another 
species  of  the  same  genus,  a  native  of  Brazil,  is  remarkable  for  the 
extremely  poisonous  and  acria  character  of  its  fruit  and  the  disgusting 
stereonaceous  odor  of  its  flowers.  Ail  parts  of  the  plant  have  a  rank 
smell." 

It  will  be  seen  from  the  above  that  there  are  many  species  of  carica 
papaya  ;  that  the  fruit  of  some  is  edible  and  of  others  not  ;  and  that  the 
juice  of  the  tree  and  its  fruit  has  the  property  of  dissolving  fibrine  simi- 
lar to  that  of  the  human  digestive  ferments.  It  may  be  added  that  some 
species  possess  this  jiroperty  to  a  much  greater  degree  than  others. 
In  fact,  the  juice  obtained  from  some  of  the  species  is  almost  inert,  while 
that  obtained  from  other  species  is  so  corrosive  as  to  attack  living  tissues, 
hence  cannot  be  used.  The  manufacturers  of  Papoid  have  spent  four 
years  experimenting  with  the  juice  of  the  trunk,  leaves  and  fruit  of 
nearly  every  known,  species  of  the  plant,  and  believe  that  in  Papoid  is  to 
be  found  tlie  purest,  niost  powerful,  and  at  the  same  time  demulcent  prep- 
aration obtainable. 


34 


Comparative  Experiments   Between  tfie   Action  of  Papoicf 

and  Pepsin. 


By  Dr.  D.  Finkler,  Professor  at  the  University  of  Bonn,  Germany. 


[The  Therapeutic  Gazette,  Philadelphia,  Aug.  15,  1887.] 

Papoid  is  a  ferment  which  is  manufactured  from  the  plant  called 
Carica  Papaya.  It  is  an  albuminous  body,  which,  under  certain  condi- 
tions, can  change  albumen  into  peptone.  The  conditions  which  produce 
this  change  are  very  different  to  those  under  which  pepsin  and  pancreatine 
produce  the  same  effect. 

In  order  to  demonstrate  the  effect  of  Papoid  I  shall  indicate  various 
experiments  made  by  myself,  which  will  give  an  exact  insight  into  the 
conditions  of  the  effect  and  also  a  comparison  of  the  effect  of  pepsin 

For  these  comparatiA^e  trials  I  used  a  pepsin  of  known  best  quality, 
most  of  the  commercial  pepsin  being  decidedly  weaker  than  that  I  used. 

First  question  :  Has  Papoid  really  a  digesting  property  ? 

Experiment  1. — a.  5  grms,  raw  meat  minced,  50  c.c.  water,  5  c.c.  of 
a  one  per  cent.  Papoid  solution  (1  grm.  in  100  c.c.  water).  This  mixture 
was  put  into  the  oven,  and  kept  for  twenty-one  hours  at  38  deg.  C.  It 
was  then  filtered.  The  filtered  portion  contains  the  albuminous  substance 
of  the  meat  turned  into  peptone^  which  is  not  precipitated  by  nitric  acid, 
nor  by  potassium  f  errocyanide  and  acetic  acid.  It  is  precipitated  by  tan- 
nic acid,  and  the  xanthoproteic  and  biuret  reactions  are  well  shown.  The 
non-peptonized  residue  of  the  meat  weighs  when  dried  0.1  grm. 

Therefore  ninety  per  cent,  of  the  solid  portions  of  the  meat  had  been 
dissolved  in  water.  Of  the  albuminous  substances  of  the  meat  eighty- 
seven  per  cent,  was  peptonized,  which  shows  a  very  energetic  degree  of 
digestion. 

b.  For  comparison,  5  grms.  raw  meat  minced,  50  c.c.  hydrochloric  acid 
(0.2  per  cent.),  and  5  c.c.  of  a  one  per  cent,  solution  pepsin  were  treated  as 
above. 

After  twenty-one  hours  70.6  jjer  cent,  of  the  albuminous  substance  of 
the  meat  was  peptonized. 

Experiment  2. — a.  5  grms.  meat,  50  c.c  water,  0.5  c.c.  of  a  one  per 
cent.  Papoid  solution. 

After  forty  hours  the  non-peptonized  residue  of  the  meat  weighed  0.19 
grm. 

Of  the  albumen  of  the  meat  77.7  per  cent,  was  dissolved  in  the  water 
as  true  peptone. 

5,  5  grms.  meat,  50  c.c.  hydrochlor.  acid  (0.2  per  cent.),  0.5  c.c.  of  a 
one  per  cent  pepsin  solution. 

After  forty  hours  the  non-peptonized  residue  weighed  0,19  grm  Of 
the  albumen  of  the  meat  77. 7  per  cent,  was  peptonized. 


35 

Experiment  3. — a.  10  grms.  meat,  20  c.c.  water,  1.5  c.c.  or  a  one  per 
Cent.  Papoid  solution. 

After  thirty-sis  hours  73.5  per  cent,  of  the  albumen  of  the  meat  was 
changed  into  true  peptone. 

h.  10  grms.  meat,  20  c.c.  hydrochlor.  acid  (0.2  per  cent.),  1.5  c.c.  of  a 
one  per  cent,  pepsin  solution. 

After  thiiiy-six  hours  eighteen  per  cent,  of  the  albumen  of  the  meat 
was  changed  into  true  peptone. 

RESUME  OF  THE  THREE  EXPERIMENTS. 


Ferment. 

Digested      albu- 
men    of     the 
meat. 

Proportion  of  the 
quantity  of  f  er- 
Time.                ment     to     the 
meat. 

Proportion        of 
the      quantity 
of  meat  to  the 
liquid. 

Papoid  1 

Papoid  2 

87.    per  cent. 
77.7  per  cent. 
73.. 5  per  cent. 

70.6  per  cent. 

77.7  per  cent. 
18.    per  cent. 

21  hours. 
40  hours. 
30  hours. 
21  hours. 
40  hours. 
36  hours. 

1  to  100 
1  to  1000 
1  to  600 
1  to  100 
1  to  1000 
1  to  600 

ItolO 
1  to  10 

Papoid  3 

Pepsin  1 

Pepsin  2 

lto2 
ItolO 

1  to  10 

Pepsin  3 

1  to  2 

Papoid,  therefore,  shows  a  more  energetic  peptonizing  power  than 
pepsin,  and  specially  so  when  the  proportion  of  the  liquid  to  the  albumen 
is  small — i.  e.,  in  the  proportion  of  concentration  in  which  food  generally 
exists  in  the  stomach  and  in  the  intestines.  The  great  variability  in  the 
quality  of  commercial  pepsin  (some  of  which  will,  under  the  most  favor- 
able circumstances,  not  peptonize  more  than  twenty  per  cent,  of  the  albu- 
men of  the  meat),  gives  Papoid  also  the  preference,  as  it  is  made  of  one 
uniform  quality. 

Second  question  :  What  effect  can  be  obtained  by  the  ferment  in  the 
human  body  ? 

a.— CONCENTRATION  OF  THE  SOLUTION  IS  OF  FIRST  IMPORT- 
ANCE. 
It  is  impossible  to  create  in  the  stomach  and  intestines  such  amount 
of  liquid  as  would  be  favorable  to  the  effect  of  pepsin.     The  conditions, 
therefore,  are  very  much  in  favor  of  Papoid. 


&.— IMPORTANCE  OF  THE  REACTION. 
Pepsin  aces  in  the  stomach,  but  not  in  the  intestines,  as  in  the  latter, 
the  reaction  is  neutral  or  alkaline.  Papoid  has  little  effect  in  the  stom- 
ach, as  the  reaction  there  is  acid.  When,  however,  the  stomach  is  neutral 
or  alkaline,  Papoid  will  peptonize,  while  pepsin  wiU.  be  useless.  The  de- 
gree (amount)  of  acid  reaction  in  the  stomach  differs  greatly,  especially 
in  case  of  a  stomach  out  of  order;  in  which  case  the  reaction  can  be  so 
highly  acid  or  alkaline  that  pepsin  would  be  of  no  value  at  all.     In  the 


36 

treatment  of  stomach-catarrh  we  will,  moreover,  find  that,  as  a  general 
rule,  the  contents  of  the  viscus  have  been  rendered  artificially  neutral  or 
alkaline  by  the  administration  of  remedies,  so  that  in  these  cases  pepsin 
will  have  absolutely  no  effect.  Papoid,  on  the  contrary,  will  act  ener- 
getically. 

c— REGARDING   THE   TIME    AVAILABLE    FOR   THE    DIGESTIVE 
FERMENT  TO  ACT  IN  THE  BODY. 

I7i  the  case  of  pepsin  this  is  necessarily  very  short,  as  the  action  ceases 
when  the  food  enters  the  alkaline  reaction  of  the  intestines.  In  the  case  of 
Papoid,  lohich  can  act  loell  in  alkaline  reaction,  the  time  is  practically  un- 
limited, as  it  continues  acting  on  the  food  during  the  whole  time  it  re- 
viains  in  the  body.  For  all  these  reasons  the  conditions  for  the  effect  in  the 
human  body  are  far  more  in  favor  of  Papoid  than  pepsin,  and  especially 
as  under  existing  circumstances  {high  degree  of  concentration)  Papoid  has 
been  shown  to  act  much  more  energetically.  It  is  only  too  clear  that  the 
preference  shoidd  be  given  to  Papoid  as  a  digestive  ferment,  for  the  treat- 
ment of  dyspepsia.  Papoid  is  also  of  great  importance  in  the  treatment 
of  diphtheria. 

Its  effective  power  consists  in  the  circumstances  that  no  free  acid  need 
be  present  in  the  application,  and  further,  that  the  moisture  of  the  diphthe- 
ritic membranes  is  quite  sufficient  to  allow  the  ferment  to  dissolve  the 
solidified  substances  of  the  membranes.  No  other  ferment  has  so  far  been 
able  to  obtain  these  results,  It  is  on  this  account  that  many  competent 
experimentalists  and  specialists  have  lately  made  observations  as  to  these 
points. 

From  all  these  circumstances  there  is  no  doubt  that  in  Papoid  we  have 
a  ferment  which  has  a  great  future  before  it.  I  have  had  the  satisfaction 
of  obtaining  the  most  favorable  results  from  its  use  in  the  treatment  of 
disease. 


Some  Laboratory  Notes  on  Papoid  Digest/on. 


By  R.  F.  RuTTAN,  B.A.,  M.D.,  Lecturer  on  Chemistry,  McGill  University, 
Montreal,  Canada. 

For  some  time  it  has  been  known  that  the  stems,  leaves  and  unripe 
fruit  of  a  plant  called  Carica  Papaya  contain  a  ferment  capable  of  digest- 
ing proteids.  This  plant  is  found  in  the  East  and  West  Indies  and  in 
South  America.  The  natives  of  many  localities  where  this  plant  is  indi- 
genous make  a  practice  of  rolling  their  fresh  meat  in  carica  leaves  to 
make  it  tender  and  easier  of  digestion.  From  the  juice  of  this  plant  is 
made  an  albuminous  preparation  containing  the  ferment,  which  is  now 
attracting  much  attention  under  the  name  of  Papoid. 


37 

About  90  per  cent,  of  commercial  Papoid  is  soluble  in  water ;  the 
residue  consists  chiefly  of  coagulated  album.en.  The  solution  contains 
globulin,  but  it  is  highly  probable  that  the  ferment  is  quite  independent 
of  this  albuminoid,  as  the  globulin  may  be  precipitated,  leaving  in  the 
solution  a  large  part,  if  not  all,  of  the  ferment. 

As  Papoid  contains  a  ferment  and  also'some  albumen  on  which  it  may 
act,  care  must  be  taken  to  keep  it  dry.  The  unsatisfactory  results  obtained 
by  some  in  its  use  are  no  doubt  due  to  previot^s  exposure  of  the  sample  to 
moisture.  A  solution  of  Papoid  will  always  give  the  peptone  reaction 
on  standing  a  few  hours. 

In  each  of  the  following  experiments  the  digestion  mixture  consists 
of  1  gramme  of  pure  dry  fibrin  in  powder,  which  was  boiled  in  20  c.c.  of 
water  and  allowed  to  stand  for  13  hours  to  soften.  To  this  was  added 
10  c.c.  of  1  per  cent,  solution  of  the  ferment  to  be  used  and  standard  acid 
or  alkali  to  required  strength,  making  the  whole  mixture  up  to  50  c.c.  The 
digestions  were  carried  on  in  an  incubator  kept  at  a  constant  temperature 
of  37-38  deg.  C,  and  at  the  end  of  a  variable  time  the  undissolved  fibrm 
was  filtered  off  on  a  small,  tarred  filter,  and  after  thorough  washing  was 
dried  at  100  deg.  to  constant  weight.  Thus  the  undigested  fibrin  could  be 
weighed  in  the  same  condition  as  before  it  was  submitted  to  the  action  of 
the  ferment,  and  any  experimental  error  caused  by  the  presence  of  a  va- 
riable quantity  of  moisture  was  eliminated. 


Experiment  I. — Digestion  mixture  consisted  of  1  gramme  fibrin.  10 
c.c.  of  a  1  per  cent,  solution  of  Papoid  or  pepsin  in  a  neutral  medium; 
time,  80  hours;  temperature,  37-38  deg.  C.   Experiment  done  in  duplicate: 

Undigested  fibrin.  Per  cent,  digested. 

Papoid  (a) 187  grm.  81.3  per  cent. 

Papoid  (&) 13      "  87.0 

Pepsin  (a) 903     "  9.7 

Pepsin  (&) 883    "  11.7 


Experiment  II. — Conditions  the  same  as  in  I,  but  in  an  acid  medium 
of  .3  per  cent,  hydrochloric  acid  ;  time,  20  hours  ;  temperature,  37-38 
deg.  C: 

.    Undigested  fibrin.  Per  cent,  digested. 

Papoid  (a)  972  grm.  2.8  per  cent. 

Papoid  (6) 923    "  7.7 

Pepsin  (a)  08      "  92.0        " 

Pepsin  (&) , 04      «'  96.0       '« 


38 

Experiment  VII. — The  action  of  Papoid  in  neutral  solution  on  diphthe- 
ritic ruembrane  compared  with  that  of  pepsin  : 

(a)  Papoid  digested  completely  .3  grm.  of  diphtheritic  membrane  in 
30  hours. 

Pepsin  had  only  partially  dissolved  the  same  weight  of  membrane  at 
the  end  of  36  hours.  * 

(6)  Papoid  dissolved  completely  .5  grm.  of  membrane  in  23-34  hours. 

In  these  experiments  a  5  per  cent,  solution  of  Papoid  or  of  pepsin  was 
added  to  the  undivided  membrane,  and  the  whole  kept  wet  during  the 
time  specified.  The  membrane  was  reduced  to  a  clear  fluid  jelly  by  Pa- 
poid, but  only  partially  attacked  by  the  pepsin  under  the  same  conditions. 

Experiment  VIII.— Does  acid  destroy  the  proteolytic  action  of  Papoid 
as  it  does  that  of  trypsin  ? 

To  ascertain  this,  .8  grm.  of  Papoid  was  added  to  1  gramme  of  fibrin 
in  a  .3  per  cent,  solution  of  hydrochloric  acid  in  duplicate.  Both  mixtures 
were  made  up  to  50  c.c  and  left  in  the  incubator  for  three  hours.  At  that 
time  one  mixture  was  estimated  and  the  other  made  faintly  alkaline  with 
sodium  carbonate  and  left  in  the  incubator  for  13  hours  longer. 

The  acid  mixture  showed  no  digestion— no  reaction  indicating  pep- 
tones could  be  obtained. 

At  the  end  of  13  hours  the  other  mixture  gave  a  residue  of  .23  grm., 
showing  that  77  per  cent,  had  been  digested. 

The  proteolytic  ferment  of  Papoid  is  therefore  not  destroyed  by  being 
kept  in  an  acid  medium  for  three  hours  at  blood  heat ;  its  action  is  only 
suspended. 

The  conclusions  to  be  drawn  from  these  experiments  are  obvious. 
Papoid  evidently  contains  a  powerful  proteolytic  ferment  which  resem- 
bles trypsin  both  in  the  conditions  under  which  it  is  most  active  and  in  its 
mode  of  digestion.  It  corrodes  the  fibrin,  dissolving  each  piece  away 
from  the  surface  to  the  centre,  and  does  not  gelatinize  the  whole  mass  Like 
pepsin.  Moreover,  one  can  readily  obtain  leucin  in  the  products  of  diges- 
tion. Tyrosin  could  not  be  obtained  by  the  writer,  but  its  presence  was 
determined  by  Dr.  Martin,  who  worked  with  larger  digestion  mixtures. 

Papoid,  as  shown  in  Experiment  II.,  is  quite  inactive  in  small  quanti- 
ties in  an  acid  medium  of  .3  per  cent,  hydrochloric  acid.  A  certain 
amount— 3  to  7  per  cent,  of  the  fibrin — was  dissolved  by  it,  but  no  true 
digestion  occurred,  as  peptones  in  any  quantity  were  absent. 

The  results  of  Experiment  VIII,  however,  show  that  although  it  is  in- 
active in  acid  its  fu.nctions  are  only  suspended — the  ferment  is  not  killed. 
This  is  interesting,  in  view  of  the  frequent  use  of  Papoid  for  treatment  of 
dyspepsia.  If  the  stomach  be  normally  acid,  its  activity  wiU  probably  be 
suspended  entirely ;  if,  however,  the  acidity  be  very  slight,  Papoid  will 
probably  act.  Its  greatest  action,  however,  takes  place  in  the  small  intes- 
tines, where  the  medium  is  alkaline  or  neutral.     The  ferment  is  most  en- 


39 

ergetic  in  a  faintly  alkaline  medium,  about  .3  per  cent,  of  sodium  car- 
bonate. In  a  neutral  medium  its  activity  is  far  greater  than  that  of 
pepsin. 

Papoid  is  especially  useful  for  removal  of  diphtheritic  membrane. 
The  conditions  present  in  the  pharynx  are  just  those  which  retard  the  ac- 
tion of  pepsin  and  pancreatin,  but  do  not  iniiuence  Papoid.  The  medium 
in  which  it  is  required  to  act  is  practically  a  neutral  one  and  the  tempera- 
ture low  ;  there  is  present,  besides,  a  large  excess  of  the  products  of  diges- 
tion which  does  not  affect  Papoid — indeed  it  is  most  energetic  in  a  concen- 
trated medium.  Moreover,  Papoid  has  been  shown  clinically  to  lessen 
very  greatly  the  disagreeable  foetor  of  the  disease.  Painting  on  a  5  per 
cent,  solution,  freshly  made,  every  two  or  three  hours,  has  been  found  to 
give  the  best  results  :  the  foetor  disappears  in  a  few  hours  and  the  mem- 
brane in  from  12-18  hours  becomes  thin  and  glairy. 

It  would  seem  to  be  especially  indicated  in  these  forms  of  dyspepsia 
in  which  j)eptic  digestion  is  greatly  impaired  and  where  the  secretion  of 
gastric  juice  is  very  weak. 

Papoid,  therefore,  j)romises  to  be  a  powerful  auxiliary  in  combatting 
those  two  great  diseases — diphtheria  and  dyspepsia. 


DECEPTIVE  PEPSIN  TESTS. 

Ryan  Hotel,  St.  Paul,  Jan.  28, 
Messes.  Johnson  &  Johnson,  New  York. 

Gentlemen  :—l  have  been  informed  that  a  representative  of  Fairchild 
Bros.  &  Foster,  New  York,  manufacturers  of  pepsin,  etc.,  has  recently 
been  here,  visiting  physicians,  and  attempting  to  show  by  the  usual  tests 
the  superior  digestive  power  of  F.  Bros.  &  Co.'s  pepsin  over  Papoid.  His 
experiments  invariably  resulted  in  apparently  proving  the  almost  worthless 
character  of  Paj)oid.  I  should  be  glad  to  learn  what  you  have  to  say  on 
this  subject.  Yours  truly,  D.  J.  BROWN,  M.  D. 


New  York,  Feb.  2d, 
D.  J.  Brown,  M.  D.,  care  Ryan  Hotel,  St.  Paul,  Mlnn. 

Dear  Sir: — Replying  to  yours  of  28th  ult*.,  we  would  say  that  if  the 
attempt  to  prove  the  relative  value  of  Papoid  and  pepsin  was  made  as 
stated  by  you,  it  was  a  species  of  deception  which  we  should  scarcely 
think  any  reputable  house  would  sanction .  It  should  be  remembered 
that  pepsin  and  Papoid  are  different  drugs ,  and  that  ordinary  tests  in 


40 

which  a  solution  favorable  to  pepsin  is  invariably  used,  do  not  apply  to 
Papoid.  We  send  you  herewith  the  reports  of  recent  experiments  made 
by  Prof.  Finkler,  of  the  University  of  Bonn,  and  Prof.  Ruttan,  of  McGill 
University,  Montreal.  You  will  note  that  in  these  tests  three  facts  re- 
garding Papoid  are  developed. 

First — That  it  has  greater  digestive  powers  than  pepsin  in  neutral  and 
alkaline  solutions,  especially  when  the  solutions  are  concentrated. 

Second — That  in  acid  (3  per  cent.)  solutions  it  is  apparently  nearly  in- 
active. 

Third — But  its  action  is,  however,  merely  suspended,  not  destroyed, 
by  acid,  hence  while  the  action  of  Papoid  upon  food  in  the  stomach  may 
be  relatively  weak  when  the  reaction  there  is  acid,  yet  when  the  food 
enters  the  intestines,  where  the  reaction  is  alkaline,  Papoid  acts  upon  it 
energetically  so  long  as  it  remains  in  the  body. 

You  can  readily  see  from  the  above  facts  that  if  Papoid  and  pepsin 
has  been  tested  in  a  neutral  or  an  alkaline  solution  instead  of  the  usual 
acid  medium,  the  results  would  have  been  exactly  the  reverse. 

'Finally ,  it  has  been  shown  by  many  eminent  authorities  that  Papoid 
has  a  remarkable  pathological  action  which  laboratory  tests  do  not  alto' 
gether  explain.  Yours  truly, 

JOHNSON  &  JOHNSON. 


PAPOID  IN  DIPHTHERIA. 

An  extract  from  the  report  of  the  proceedings  of  the  Montreal 
Medico- Chirurgical  Society,  Nov.  25th,  1887  : 

' '  Dr.  Geo.  Ross  said  he  was  trying  the  local  application  of  Papoid  in 
diphtheria.  It  was  applied  by  means  of  a  brush  in  five  per  cent,  solution 
every  half  hour.  In  hospital  (Montreal  General)  he  had  treated  26  cases, 
many  of  them  severe,  and  some  of  tljem  very  severe.  Of  these,  13  were 
discharged  well ;  12  remained  under  treatment,  but  he  thought,  without 
doubt,  would  all  recover  ;  one  only  died.  He  was  certainly  favorably  im- 
pressed with  the  action  of  the  drug,  but  could  not  say  more  than  this  until 
extended  observations  had  corrected  or  confirmed  first  impressions." — 
Canada  Medical  and  SurgicalJournal,  Feb.,  1888,  pp.  424. 


41 


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42 
Directions  for  tiie  Administration  of  Papoid  in  Dyspepsia, 


By  Professor  Finkler. 


Papoid,  when  taken  into  the  stomach  has  the  folio  v^ing  action  : — 

1.  It  converts  five  times  as  much  albumen  into  peptone,  bulk  for  bulk, 
as  the  best  pepsin. 

2.  It  increases  the  flow  of  gastric  juice,  by  stimulating  the  peptic 
glands. 

3.  It  prevents  the  decomposition  and  fermentation  of  the  contents  of 
the  stomach  by  its  antiseptic  action. 

4.  The  action  commenced  in  the  stomach  is  continued  after  the  food 
has  passed  into  the  intestines,  as  it  acts  in  the  presence  of  an  alkali. 

5.  It  is  perfectly  harmless. 

6.  It  dissolves  any  unhealthy  mucus  sheathing  the  walls  of  the  stom- 
ach and  intestines,  and 

.  7.     It  relieves  pain,  either  caused  by  the  presence  of  irritating  ingesta, 
or  due  to  local  neuralgia. 

It  is  thus  evident  that  the  drug  will  prove  useful  in  all  cases  where 
there  is  either  deficient  secretion  of  the  peptic  ferments,  abnormal  fermenta- 
tion, or  a  combination  of  both  conditions. 

In  practice,  excellent  results  have  been  obtained  in  the  following  con- 
ditions : — 

1.  Gastric  or  intestinal  pain. 

2.  Vomiting,  persistent,  especially  the  morning  sickness  of  chronic 
alcoholism,  and  that  incidental  to  pregnancy. 

3.  Anorexia,  simple  loss  of  appetite  without  other  symptoms. 

4.  Acid  dyspepsia. 

5.  Chronic  catarrh  of  the  stomach,  especially  that  due  to  alcoholism. 

6.  The  chronic  stomach  catarrhs  of  children.  Here  it  apparently  acts 
by  dissolving  the  unhealthy  mucus  which  sheaths  the  walls  of  the  stomach 
and  prevents  the  proper  absorption  of  the  food. 

7.  Cases  of  ordinary  slow  digestion. 

8.  And  lastly,  that  form  of  irritative  dyspepsia  which  is  the  common 
result  of  rapid  eating  and  imperfect  mastication. 

From  this  long  list  we  see  that  it  will  prove  beneficial  in  most  of  the 
disorders  of  the  digestion,  in  some,  its  effects  being  so  marked  as  to  make 
it  appear  a  veritable  specific. 

Dose  of  Papoid. — The  ordinary  dose  of  this  drug  is  from  gr.  ss — gr. 
jss  for  children,  and  gr.  jss — gr.  v.  for  adults.  Larger  doses  have  been 
given  without  injurious  effects  in  certain  cases,  but  in  the  usual  run  of 
cases  it  has  not  been  found  necessary  to  exceed  gr.  v.  as  a  rule.  In  most 
instances  gr.  jss  to  gr.  ij  will  be  found  quite  a  large  enough  dose. 


43 

Method  of  Administration. — Either  in  powder,  pill  or  mixture.  It 
is  very  hygroscopic,  and  will  not  keep  its  activity  long  ex- 
cept in  a  dry  state.  So  when  ordered  in  a  mixture,  only  a  few  doses 
should  be  put  up  at  a  time. 

Time  of  Administration. — During  or  after  a  meal,  except  in  cases  of 
catarrh,  where  its  local  action  on  mucus  is  required  when  it  should  be 
given  just  before,  or  half  the  dose  may  be  given  before  the  meal,  and  the 
remainder  during  its  progress. 

Where  there  is  abnormal  fermentation  of  the  contents  of  the  stom- 
ach, its  antiseptic  action  may,  with  advantage,  be  increased  by  the  addi- 
tion of  another  drug,  by  preference  Boracic  Acid,  which  acts  very  well 
with  it,  or  a  dose  of  pure  Glycerine  may  be  given  immediately  before  the 
meal,  and  the  Papoid  afterwards.  This  latter  mode  of  treatment  is  espe- 
cially useful  in  those  cases  of  "  Irritative  dyspepsia  "  due  to  rapid  eating. 
The  usual  symptom  in  such  cases  is  distress  coming  on  half-an-hour  or  an 
hour  after  meals.  There  is  also  duodenal  catarrh  and  dyspepsia,  with, 
perhaps,  slight  jaundice  and  other  symptoms,  referable  to,  and  explained 
by,  the  irritated  raucous  membrane  of  the  stomach  and  duodenum.  The 
indications  in  such  cases  are  well  defined:  (a),  we  must  prevent  the  food 
from  undergoing  mischievous  chemical  changes  before  it  can  be  acted 
on  by  the  enfeebled  digestive  organs  ;  (&),  a  remedy  must  be  given  which 
will  soothe  the  irritated  mucous  surface,  these  two  indications  being  ful- 
filled by  the  Glycerine  ;  and  (c),  we  must  supplement  the  poverty  of  the 
gastric  and  pancreatic  secretions  by  the  administration  of  Papoid. 

The  following  are  a  few  eligible  formula  for  the  administration  of 
the  drug  in  the  cases  mentioned  above  : — 
jR.  Papoid  gr.  jss. 

Sod.  Bicarb,  gr.  iiij. 

Pulv.  Trochisc, 

Menth.  Pip.  gr.  iij  M.  fiat  pulv.  j. 

To  be  taken  three  times  a  day  after  meals  in  a  Kttle  water. 
(Powdered  Peppermint  lozenge  is  the  nearest  approach  we  have  to  the 
Oleo-Sacch.  Menth  Pip.  of  the  Pharm;  Germanic. 

In  cases  of  very  delicate  stomach  it  may  be  given  in  a  mixture,  as 
follows  : — 

B.  Papoid  gr.  xviij — gr.  xxxvj. 
Mucilag.  Acac.  oz.  j. 

Aq.  ad  oz.  vj  M.  fiat.  mist,  cujus  cap.  coch.  mag.  unum 
ter  die  post  cibum. 
When  there  is  fermentation  and  decomposition  of  the  contents  of  the 
stomach,  w^e  order — 

R.  Papoid  gr.  jss. 

Acid  Boracic  gr.  jss  M.  fiat  pulv.  j  Bis  terve  in  diem 
sumend. 


44 

When  there  is  distinct  anaemia  we  may  combine  it  with  reduced  iron 
or  quinine,  and  in  cases  of  atony  of  the  stomach  and  dilatation,  with 
strychnine.  In  these  cases  it  is  best  given  in  pill  form.     For  example  :— 
B.  Papoid  gr.  ij. 

Quin.  Sulph.  gr.  j. 

Saa.  Lactis.  gr.  j  Mucil.  Tragac.  q.  s.  ut  fit  pil  j  ter  die 
sumend  post  cibum. 

Sugar  of  Milk,  with  a  little  Mucilage  of  Tragacanth,  has  been  found 
to  be  the  best  excipienc  to  use,  and  pills  made  with  it,  well  dried,  and 
coated  with  a  solution  of  Gum  Sandarach  in  absolute  alcohol,  will  keep 
indefinitely,  as  the  interior  cannot  absorb  moisture,  owing  to  the  imper- 
meable coating.  In  cases  of  great  acidity,  large  doses  of  an  alkali,  such 
as  Sod.  Bicarb. ,  may  be  combined  with  the  Papoid,  as,  unlike  pepsin,  its 
action  is  not  interfered  with  thereby. 

In  some  cases  of  hyperacidity  of  the  stomach,  due  to  the  formation 
of  fatty  acids  in  the  process  of  digestion,  the  best  result  is  sometimes  ob- 
tained by  giving  a  dose  of  Papoid  with  the  meals,  and  following  it  after 
an  interval  of  about  an  hour  by  15  min.  of  dilute  Hydrochloric  Acid,  as 
Leube  has  found  in  these  cases  a  distinct  deficiency  of  the  latter  in  the 
stomach  secretion. 

For  children,  the  following  formula  has  been  very  successful,  given 
before  meals,  when  there  has  been  catarrh  of  the  stomach  : 
B.  Papoid  gr.  jss— gr,  j. 
Sac.  Lactis  gr.  j. 
Sod.  Bicarb,  gr.  v.  M.  fiat.  pulv.  j.  Ter  die  sum. 

For  the  immediate  relief  of  Vomiting,  give  gr.  iij.  of  Papoid  in  half 
a  tumbler  of  soda  water  on  an  empty  stomach. 

1.  Relief  of  Pain:  a,  Gastric  ;  6,  Intestinal. — Papoid  relieves,  and 
sometimes  entirely  removes,  gastric  pains,  which  have  their  origin  in  the 
irritation  of  the  mucous  membrane  of  the  stomach.  It  is  especially  use- 
ful in  extreme  acidity,  chronic  catarrh,  and  also  in  dyspepsia  of  nerve 
origin.  It  will  completely  remove  that  heavy  feeling  of  pressure  so  often 
experienced  by  dyspeptics  after  a  full  meal.  For  the  relief  of  pain  it  is 
most  effective  in  combination  with  Sod.  Bicarb,  and  .01  Menth.  Pip. 

3.  Relief  of  Vomiting.— The  distressing  vomiting  which  so  often  oc- 
curs in  attacks  of  gastric  catarrh,  and  particularly  the  morning  sickness 
of  chronic  alcoholism,  is  almost  invariably  relieved.  The  drug  is  contra- 
indicated  in  cases  of  actual  ulceration  of  the  mucous  membranes. 

3.  One  of  the  most  striking  effects  observed  in  patients  who  are  taking 
the  drug  is  the  very  great  improvement  in  appetite  which  invariably  fol- 
lows the  exhibition  of  it  after  even  a  few  doses. 

In  cases  of  ordinary  dyspepsia  following  excess,  either  in  eating  or 
drinking,  Papoid  relieves  at  once  the  pressure  and  heavy  feeling  in  the 
stomach.     In  the  treatment  of  such  cases  I  give  a  small  dose  I'f  the  Carls- 


45 

bad  Sprudelsalz  in  the  morning  in  a  small  tumbler  of  an  effervescing  min- 
eral water,  and  after  lunch  and  dinner  I  give  Papoid,  gr.  iss-4,  dissolved  in 
a  little  water  and  taken  a  quarter  of  an  hour  after  the  meal. 

In  chronic  gastric  catarrh  I  give  the  following  prescription  : — 
B.  Papoid  gr.  iss. 
Sod.  Bicarb. 

Oleosacch.  Menth.  pip.  aa.  gr.  iii.  M.  Ff.  pv.  i.      Ter  die  sumend. 
in  aqua  post  cibum. 

The  indications  for  the  administration  of  the  drug  in  these  cases  are 
acid  eructations,  pyrosis,  and  gastric  pain  and  pressure.  In  cases  of  dila- 
tation of  the  stomach  one  employs,  in  addition,  the  ordinary  treatment  of 
washing  out  the  stomach  and  the  application  of  electricity,  as  the  two 
modes  of  treatment  do  not  interfere  with  each  other. 

Another  advantage  that  Papoid  has  over  pepsin  lies  in  the  fact  that 
the  percentage  of  HCl  in  the  stomach  is  always  very  much  increased  in 
chronic  catarrh,  and  as  pepsin  only  acts  in  the  presence  of  a  constant 
amount  of  acid  (.02  per  cent.),  and  is  inoperative  at  high  or  low  percent- 
ages, and  as  the  state  of  the  stomach  in  chronic  catarrh  usually  varies  be- 
tween the  state  of  hyperacidity  and  the  state  of  slight  alkalinity  induced 
by  the  efforts  of  the  patient  to  obtain  relief  by  taking  large  doses  of 
neutralizing  alkalies,  pepsin  has  no  effect  whatever,  while  Papoid  com- 
mences to  act  at  once.  In  other  words,  Papoid  has  the  advantage  over 
pepsin  that  in  cases  of  stomach  disease  accompanied  by  great  excess  of 
acid  in  the  stomach  it  can  be  given  with  a  sufficient  quantity  of  alkali 
to  neutralize  the  excess  aforesaid  without  impairing  its  own  action,  I 
beheve  that  the  action  of  pepsin  taken  internally  has  been  very  much 
overrated.  The  further  advantages  of  Papoid  are  in  its  other  properties. 
Firstly,  its  effect  upon  the  sensitive  nerves  of  the  stomach ;  this  has  been 
proved  practically,  and  also  by  experiments  on  animals  byRossbach.  Its 
soothing  effect  in  gastric  pain  no  doubt  arises  from  this.  And  secondly, 
Papoid  has  also  a  tonic  effect  upon  the  mucous  membrane  of  the  intes- 
tines. This  has  been  experimentally  proved  on  animals,  and  points  out 
indications  for  its  employment  in  many  diseases  of  those  organs.  In  cases 
of  anaemia  Papoid  is  best  given  in  combination  with  small  doses  of  quinine, 
or  with  Rhizom.  Calami. 
a.  Papoid  gr.  iss. 

Rhizom.  Calami  gr.  ivss.  M.  Ft.  pv.  j.  Capiat  ter  die  ante  cibum. 

In  many  chronic  cases,  and  especially  in  those  where  the  cause  of  the 
disease  cannot  be  removed,  such  as  carcinoma  and  stricture  of  the  pylorus, 
I  have  given  Papoid  for  months  without  observing  any  untoward  effect. 

DIRECTIONS  FOR  THE  USE  OF  PAPOID  IN  DIPHTHERIA, 

The  action  of  the  drug  upon  which  we  depend  for  its  use  in  diphthe- 
ria, is  the  same  as  that  which  makes  it  so  valuable  in  the  treatment  of  the 
disorders  of  digestion,  viz.,  its  power  of  dissolving  and  peptonizing  fibrin. 
When  applied  to  the  diphtheritic  membrane  it — 

1.  Dissolves  and  detaches  it  in  a  few  hours. 

3.  It  destroys  the  infective  organism  of  the  disease  by  its  germici- 
dal action,  and  thus  prevents  any  fresh  infection  of  the  system. 

3.  It  causes  an  almost  immediate  faU  of  the  body  temperature,  with 
the  simultaneous  disappearance  o£  the  diphtheritic  membranes.'  The 
rationale  of  this  being  that  the  organisms  which  are  already  in  the  system 
soon  perish,  and  no  fresh  ones  being  absorbed,  there  is  nothing  to  keep  up 
the  abnormal  fever. 


46 

4.  It  adheres  persistently  to  fibrin.  Some  experiments  made  by 
French  savants  prove  that  fibrin  once  in  contact  with  Papoid  does  not 
give  up  the  latter,  in  spite  of  most  energetic  washing  with  water,  so  that 
when  once  applied  to  a  diphtheritic  membrane,  nothing  can  pj-event  the 
latter  from  being  completely  destroyed. 

We  shall  now  pass  to  the  consideration  of  the  best  manner  of  using 
the  drug  in  the  treatment  of  this  disease.  As  all  my  readers  may  be  as- 
sumed to  be  practically  familiar  with  the  ordinary  modes  of  internal  med- 
ication, and  as  they  will  not  be  interfered  with  by  the  Papoid  treatment, 
but  may  and  should  be  carried  on  pari-passu  with  it,  I  shall  confine  my 
remarks  to  the  few  practical  points  which  have  arisen  in  the  recorded 
cases,  and  the  conclusions  that  have  been  arrived  at  by  their  consideration 
as  to  the  best  method  of  administering  the  drug.  IT  MAY  BE  APPLIED 
IN  SOLUTION  ;  then— 

1.  The  best  strength  to  use  is  a  5  per  cent,  solution. 

2.  It  should  be  applied  at  least  every  half -hour. 

3.  In  mild  cases,  where  the  false  membranes  are  confined  to  the 
pharynx,  it  may  conveniently  be  applied  with  a  soft  brush. 

4.  In  severe  cases,  or  where  there  is  the  slightest  indication  that  the 
membranes  are  spreading  to  the  larynx,  or  nasal  passages,  I  would  advise 
the  use  of  a  spray.  If  the  patient  is  old  enough  he  should  be  made  to 
open  the  mouth,  and  the  spray  directed  to  the  back  of  the  pharynx,  but  if 
too  young  to  do  so  the  solution  should  be  sprayed  in  front  of  the  nose  and 
mouth  so  that  the  drug  will  be  carried  into  the  respiratory  passages  by 
the  acts  of  breathing.  This  application  of  spray  must  be  done  by  the  use 
of  a  spray-producer  that  acts  hj  atomizing  the  liquid,  as  in  the  ordinary 
scent-spray,  and  not  by  means  of  a  steam-spray  apparatus,  wliich  will 
dilute  the  solution,  and  thus  make  it  less  efficacious. 

5.  Early  tracheotomy  is  to  be  advised  in  suitable  cases  ;  and  besides 
the  application  of  the  spray  over  the  orifice  of  the  tracheotomy  tube,  a 
few  drops  of  the  solution  should  be  allowed  to  trickle  down  the  tube. 
The  Papoid  solution  must  be  warm,  this  being  conveniently  effected  by 
standing  the  spray  apparatus  in  a  vessel  of  water  about  100  deg.  Fahr. 

6.  For  diphtheria  of  the  nasal  passages  it  is  most  convenient  to  use  a 
spray-producer  with  a  conical  nozzle,  which  fits  in  the  orifice  of  the  nose 
tightly,  as  it  can  be  applied  with  ease  to  a  struggling  child.  That  form 
known  as  Leffert's  is  one  of  the  best.  In  diphtheria  of  the  naso-pharynx, 
if  the  patient  is  old  enough,  a  post-nasal  spray  tube  should  be  used. 

OR  IT  MAY  BE  USED  AS  A  THIN  PASTE  OR  STRONG  SOLU- 
TION. 

Professor  Finkler  now  uses  the  following  method,  to  the  exclusion  of 
all  others,  and  says  that  he  obtains  much  better  and  quicker  results.     He 
rubs  up  gr.  v.  of  the  drug  with  a  spatula,  with  as  much  water  as  will  dis- 
solve it  into  a  thin  paste,  and  applies  it  to  the  membrane  with  a  brush  every 
hour,  or  half  hour.     The  physician  should  prescribe  it  in  powders,  as  fol- 
lows, each  powder  containing  sufficient  for  one  or  more  applications — 
R.  Papoid  gr.  v. 
Ft.  chart,  j. 
Sig.     One  powder  to  be  rubbed  up  with  sufficient  water  to  dissolve  it,  and 
applied  with  a  brush  to  the  throat  as  often  as  directed.    Dispense  in 
waxed  paper. 

One  should  never  mix  more  than  is  required  for  one,  or  at  the  most 
two,  applications  at  a  time,  as  in  lengthened  contact  with  water  the  drug 
loses  some  of  its  power  of  dissolving  membrane. 


47 

Whenever  there  is  reason  to  think  that  the  membranes  are  spreading 
downwards  towards  the  larynx,  or  upwards  towards  the  nasal  passages, 
the  5  per  cent,  spray  should  be  used  in  addition  to  the  above  brushing 
with  strong  solution. 


Papoid  Tablets  and  Compressed  Pills. 

In  ordej-  to  have  these  formulce  in  a  convenient  form  for    the 
physician,  we  have  prepared  compressed  tablets,  each  containing: 

Papoid  gr.  i 
Sod.  bicarb,  gr.  ii. 
Sac.  lacti  qs. 

Also,  compressed  tablets,  each  containing: 

Papoid  gr.  iss.  • 

Acid  boracic  gr.  iss. 

Also,  Papoid  Pills,  1  gr.  each,  compressed  or 
gelatine  coated. 
May  be  procured  from  your  pharmacist. 

JOHNSO]^  &  JOHNSON, 

23  Cedar  St.,  New  York. 


TO  THE  PROFESSION. 


Since  we  became  agents  for  Papoid  many  thousands  of  ounces  have 
been  consumed  in  the  United  States  and  Canada. 

It  is  now  being  used  in  all  the  larger  cities  and  in  most  of  the  small 
towns. 

Many  of  our  leading  medical  journals  have  published  reports  from 
physicians  regarding  its  value,  which,  with  one  exception  only,  are  favor- 
able. During  the  past  three  months  our  correspondence  with  physicians 
regarding  the  article  has  been  large,  and  of  the  reports  thus  received 
eighty-nine  per  cent,  have  been  unqualifiedly  favorable,  six  per  cent, 
partially  so,  and  five  per  cent,  state  that  the  results  obtained  were  unsatis- 
tac  ory. 

On  the  whole,  the  reports  confirm  the  opinions  of  the  foreign  authori- 
ties lately  published,  and  lead  to  the  conclusion  that  Papoid  will  largely 
displace  pepsin,  pancreatine  and  other  digestive  ferments. 

Special  attention  is  called  \o  the  convenience  of  Papoid  and  Soda  and 
Papoid  and  Boracic  Acid  Tablets,  made  after  Prof.  Finkler's  prescriptions, 
for  use  in  the  treatment  of  Dyspepsia. 

Having  received  complaints  regarding  the  price  of  Papoid,  we  would 
state  that  it  is  as  low  as  it  can  be  made  under  the  existing  conditions  of 
manufacture,  and  that  as  the  dose  of  Papoid  is  only  about  one-third  that 
of  Pepsin,  the  former  will  be  found  quite  as  cheap,  if  not  cheaper,  than  the 
best  quality  of  the  latter  article. 

JOHNSON  &  JOHNSON. 


AS 
IMPROVED   BELLADONNA   PLASTERS. 


INCREASED  ACTION. 


Several  years  ago  our  attention  was  called  to  a  wild  belladonna  root. 
Repeated  tests  proved  that  not  only  did  the  root  yield  a  greater  per  cent, 
of  solid  extract,  but  that  the  extract  itself  was  much  richer  in  atropia, 
yielding  uniformly  over  4  per  cent,  of  the  alkaloid,  and  from  10  to  40  per 
cent,  more  than  could  be  obtained  from  extracts,  made  from  ordinary  com- 
mercial belladonna  root. 

It  can  readily  be  seen  that  the  great  difference  in  the  yield  of  atropia 
from  the  ordinary  belladonna  extracts,  made  the  task  of  preparing  bella- 
donna plaster  of  uniform  strength  very  difficult.  By  the  use  of  wild  root, 
obtained  from  one  locality,  uniformity  in  the  percentage  of  atropia  in  the 
plaster  at  all  times  is  secured. 

That  the  addition  of  boracic  acid  to  belladonna  plaster  decidedly 
increases  the  therapeutic  action  of  the  drug,  is  shown  by  the  experiments 
of  Drs.  John  V.  Shoemaker,  D.  H,  Agnew  and  others. 


Says  Dr.  Shoemaker,  in  a  paper  read  before  the  Pennsylvania  State 
Medical  Society,  June  28th,  1887: 

"  The  addition  of  boracic  acid  in  the  proportion  just  named  to  belladonna  has  some 
action  upon  the  fatty  matter  of  the  skin,  and  renders  the  effect  of  the  former  drug  more 
decided. 

"  It  is  one  of  the  most  effective  plasters  for  relieving  recmrent  patches  of  herpes,  herpes 
zoster,  neuralgia,  and  exalted  and  diminished  sensibiUty  of  the  skin.  In  isolated  spots  of 
erythema,  subacute  and  chronic  eczema,  it  often  reheves  the  accompanying  obstinate  itch- 
ing and  removes  the  infiltration. 

"  Local  sweating  in  different  parts  of  the  body  may  be  often  reUeved  or  cured  by  the 
application  of  this  plaster.  It  is  particularly  serviceable  in  both  excessive  and  fetid  per- 
spiration of  the  hands  and  feet.  In  cases  in  which  the  feet  sweat  the  epidermis  peels  off, 
the  skin  cracks  and  becomes  tender.  The  continuous  application  of  belladonna  and  boracic 
acid  plaster  for  days  is  frequently  followed  by  a  complete  removal  of  all  the  symptoms. 

"  In  the  same  way  fissured  eczema,  especially  of  the  fingers  and  toes,  may  often  be 
controUevl  and  healed  by  encircling  the  parts  with  the  plaster  every  two  or  three  days. 
Localized,  obstinate  and  irritable  patches  of  vegetable  parasitic  diseases,  especially  ring- 
worm and  favus,  may  yield  readUy  to  the  use  of  this  plaster.  The  boracic  acid  in  the  com- 
bination is  one  of  the  most  effective  anti-parasitic  agents  for  the  destruction  of  vegetable 
organisms,  and  the  belladonna  acts  well  in  relieving  cutaneous  irritation.  The  action  of 
belladonna  plaster  in  arresting  the  secretion  of  mUk  and  in  reheving  inflammation  of  the 
breasts,  is  in  this  combination  still  more  enhanced  in  its  effect  by  the  boracic  acid.  The 
absorption  of  the  belladonna  is  found  to  take  place  more  rapidly,  and  the  secretion  of  milk 
and  the  inflammation  yield  more  promptly  to  the  application  of  the  two  drugs  in  the  form 
just  suggested.  Abscesses,  boUs  and  carbuncles,  inflamed  subcutaneous  glands,  irritable 
scalds,  frost-bites,  wounds  and  lilcers  may  be  beneflted,  and  at  times  speedily  induced  to 
heal,  by  the  local  anodyne  action  of  the  belladonna  and  the  antiseptic  properties  of  the 
boracic  acid." 

JOHNSON   &  JOHNSON. 


DR.  COLE'S  THROAT  SPECULUM. 


Accurate' diagnosis  lies  at  the  foundation  of  all  rational  treatment  of  disease.  "We 
therefore  beg  to  offer  to  the  profession  a  new  and  unique  instrument  intended  to  f  aciUtate 
the  diagnosis  and  treatment  of  Throat  Affections.  So  great  is  the  siuipUcity  and  adapta- 
bility of  Dr.  Cole's  Speculum  that  no  special  training  is  required  in  its  use.  The  instnunent  is 
constructed  of  an  upper  and  a  lower  section,  hinged  together  at  the  sides,  as  wQl  be  seen  by 
reference  to  the  accompanying  cut.  The  upper  section  is  provided  with  %vlngs  or  flanges, 
on  which  the  upper  molar  teeth  rest,  and  a  depression  in  front,  toengagethe  upper  incisors. 
By  this  arrangement  it  becomes  a  fixed  fulcrum,  thus  securing,  by  the  action  of  the  lower 
jaw,  the  leverage  necessary  to  the  depression  and  retraction  of  the  t-^ngue.  Its  capacity 
for  illuminating  the  throat  is  an  advantage  which  it  possesses  ovjr  all  other  Specula  now  in 
use.  It  is  provided  with  a  reflector,  so  arranged  as  to  reflect  the  light  into  the  throat,  bring- 
ing into  view  all  parts  of  the  same,  and  thus  rendering  easy  the  diagnosis  and  treatment  of 
a  lai-ge  and  important  class  of  diseases.  We  especially  recommend  it  to  the  profession  for 
its  advantages  in  examinations  by  artificial  light.  The  instrument  being  automatic  and 
self-adjusting,  there  is  nothing  intervening  to  obscure  the  view  of  the  operator,  and  both 
hands  are  left  free  to  work.  It  is  made  of  pure  Gterman  silver,  nickel  plated,  in  sets  of  foiu- 
sizes,  and  adapted  to  persons  of  all  ages.  It  is  put  up  in  elegant  morocco  cases,  and  sold  at 
§5.00  per  set. 

Will  be  sent  by  mail  on  receipt  of  price,  or  by  expre.ss  C.  O.  D.,  ivitU  the 
privilege  of  returning  after  one  month's  trial,  and  having  payment  refunded 
if  unsatisfactory. 

For  further  particulars  address 

JOHNSON   &  JOHNSON, 

Sole  -^geix-ts, 
23   CEDAR   ST.,  NEW   YORK 


EEFERENCES. 


Prof.   T.    B.   HARVEY,  M.  D., 
"      WM.  B.  FLETHER,     " 
"      J.  S.  COMINGORE,      " 
'•      JOSEPH  EASTMAN,  " 
'■      L.  ABBOTT,  " 

Dr.  J.  D.  GEORGE, 
"    P.  W.  PAYNE,  Franklm,  Ind. 
"    T.  W.  CURRY,  South  Port,  Ind. 


Prof.  HENRY  JAMESON,  M.  D. 
"      A.  MAXWELL, 
"     GEORGE  HASTY, 
"     A.  ANTHONY, 

Indianapolis,  Ind. 

Dr.  S.  G.  HASTINGS, 
"    J.  S.  MARTIN,  Muncie,  Ind. 
"    J.  W.  GREEN,  Shelbyville,  Ind. 


COLUMBIA  UNIVERSITY  LIBRARY     | 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C28(239)M100 

RD131  J63 

1891 
Johnson  5:  Johnson  j 


L 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  131  J63  1891  C.I 

■„v,rc--  ~-~ — -  -'  ■--■  —"  '  :.:r<:  '/eat 


III  Hill  lllll  Hill  lilllllllllllF 

2002127091 


